What you need to know to prepare for your mastectomy with aesthetic flat closure
Note: This information is not intended to replace your surgeon’s instructions, but to supplement them so that you are better prepared to make your recovery process as smooth as possible. Always follow your surgeon’s instructions, and call them with any concerns you may have. For questions or comments about this page, email us at firstname.lastname@example.org.
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What is a Mastectomy with Aesthetic Flat Closure?
Mastectomy is the surgical removal of the breast tissue including the nipple to treat or prevent breast cancer.* Your surgeon may also remove one or more lymph nodes from under your arm. You may have a single breast removed, or both. For women who want conventional breast reconstruction, their surgeon may suggest a “skin-sparing” or “nipple-sparing” procedure. More about the mastectomy process itself at BreastCancer.org.
Aesthetic flat closure is surgical contouring of the chest wall to produce a smooth, flat result post-mastectomy. This can be done at the time of the mastectomy, at a subsequent revision surgery, or after explant. Also known as “going flat,” aesthetic flat closure is a valid and healthy reconstructive alternative to conventional breast mound reconstruction (eg. implants, autologous flaps). After the removal of the breast tissue, i.e. the mastectomy itself, an additional 30-60 minutes of surgical contouring work may be required to produce an aesthetic flat closure.
- * Note: mastectomy can also be done as part of the gender confirmation process, unrelated to breast cancer.
A Note About Revision Surgery
Visit the Revision Surgery Page
Revision is “Corrective” Surgery. After a mastectomy without conventional reconstruction, some patients find themselves with a less than optimal aesthetic outcome. Unless you have a medical contraindication, revision surgery is an option to improve your chest wall contour, should you decide to pursue it. In our 2019 survey, revision drastically improved patient’s satisfaction with their aesthetic outcome. But not everyone is willing to undergo additional surgery to achieve a “flatter” chest. It’s a very personal decision.
Procedure & Recovery. Revision surgery can look very different for different patients. For minor “nips & tuck” revisions, the procedure can often be done in office with local anesthetic and may involve only a short recovery period of a week or two. More extensive revisions for very large “dog ears” and significant excess skin may involve general anesthesia, surgical drains, and a longer recovery process approaching that of your initial mastectomy. Speak with your revision surgeon about your specific medical situation and what to expect for your surgery. For tips on finding a revision surgeon, visit the Revision Surgery page.
Single or Double?
Removal of the unaffected breast at the time of a mastectomy for unilateral breast cancer is called “contralateral prophylactic mastectomy” (CPM). In the absence of genetic risk factors that elevate your risk for a new primary breast cancer, the decision to pursue CPM is generally at the discretion of the patient.
Reasons to Keep the Unaffected Breast
- Risk of PMPS (Post-Mastectomy Pain Syndrome) and other complications of surgery may be increased proportional to the extent of the surgery
- More extensive surgery usually means a longer recovery period
- CPM does not provide any significant survival benefit or recurrence risk reduction
- Retain nipple sensation – this can affect sexual function for some women
- Retain ability to lactate – may be a concern for younger women
- Finding bras and clothing that fit well may a challenge
Reasons to Remove the Unaffected Breast (CPM)
- CPM maximally reduces the risk of a new primary breast cancer
- Aesthetic symmetry is more appealing for some women. Some find the asymmetry of their initial single mastectomy disturbing and eventually pursue CPM to resolve this
- Both breasts are gone in one surgery, no need for a future mastectomy
- No more mammograms – this may have psychological as well as logistical benefits
- No more bras needed
- Finding clothing that fits well may be somewhat easier
Studies clearly show that CPM does not improve survival or significantly reduce your risk of recurrence, either local or metastatic, of your initial breast cancer. But it does reduce your risk of a new primary breast cancer, and that risk reduction can be more significant for younger women. Discuss CPM with your surgeon so that you can understand the risks and benefits of keeping or removing the unaffected breast. It can also be helpful to speak with other women who have lived single-breasted, and those who decided to have a double mastectomy, about their experiences (more).
Before Your Surgery: What You Should Know
Pre-Surgery Checklist & Supply List
- Ensure your surgeon is on board with your choice: aesthetic flat closure
- Discuss any known sensitivities you have to surgery related medicines/materials
- Initial visit with a lymphedema certified physical therapist
- Sleeping environment set up to your liking
- Contact information for your surgeon’s office, including after hours
- Help lined up: personal assistant for the first week, caregiver stand-in(s), house cleaner
- Meals prepared for 1-2 weeks, easy high protein/fiber snacks
- Driver to ferry you to and from the hospital on the day of surgery
- Driver to take you to your post-op checkup and drain removal
- Small pillow or folded towel in the car on surgery day to pad your seatbelt
- Foam wedge and/or 6-8 pillows to prop you for sleep
- Alcohol wipes to assist with stripping the drains
- Silicone scar sheets (if you’re prone to keloids – ask your doctor)
- Plastic lanyard or necklace for hanging drains while showering
- Zip-front or button down shirt/dress/robe(s)
- Reusable drinking cup with straw (for bedside)
- Supply of over the counter painkillers (ex. Tylenol – ask your doctor)
- Entertainment that doesn’t require much or any use of your arms (ex. TV with remote control, radio, audio books, music)
Don’t forget to visit Breast Cancer Freebies for assistance obtaining supplies like drain holder bags, wigs and accessories, and more.
Personal Assistance: You Will Likely Need Help for 1-2 Weeks
For the initial recovery period after your mastectomy, i.e., the first 1-2 weeks, you may need assistance with basic self-care duties. Some patients manage fine on their own, but others struggle, and it’s better to be prepared. Routine chores like preparing food, washing dishes, and light housework should all be minimized initially to prevent overuse of the arms, which engages the muscles underlying the mastectomy site. Rest is critical in allowing those tissues to heal.
If you have a partner, friend, family member or neighbor who can assist you for part or all of the day, it will help you to focus on resting and healing. Also, you will not be able to drive until your surgical drains are removed and you are no longer taking narcotic painkillers. Line up help in advance, with backup if possible. If you live alone and aren’t sure who to ask for help, ask your doctor’s office for recommendations or contact a patient services organization like Triage Cancer for assistance.
Considerations for Caregivers
If you are a primary caregiver of small children or other dependents, you should know that during the first couple of weeks after your surgery you will most likely be unable to fulfill any of your usual duties that involve engaging your chest muscles. That includes any lifting or carrying of your dependent charge. Even walking a dog, especially a large dog, is unadvisable during your initial recovery period.
While everyone’s recovery is different, it’s hard to predict in advance. Making the following preparations will ensure that you won’t be tempted to overexert yourself when you should be resting after your surgery:
- Stand-In Caregiver. Arrange for an alternate caregiver to be available for at least a week, but ideally for at least 2-4 weeks.
- Meals. Stock your freezer with ready to heat meals. Focus on protein and fiber to promote healing and regularity, and keep some high protein/fiber snacks on hand that don’t require any preparation.
- Housework. If you can, arrange to outsource housework for a week or two (or more).
- Pillow behind your back to recline
- Pillows to elevate each arm
- Easy to reach water cup, pain meds, phone, charger
- Elevated beds only, no floor beds (requires arms to get up)
More tips to prepare for your mastectomy can be found at Flat & Fabulous.
Wherever you plan to sleep during your recovery, you should be able to get in and out of the sleeping position easily without requiring the use of your arms. This typically means sleeping with your back leaning against a pile of pillows, or on a foam wedge. Some people find that sleeping in a recliner provides a more comfortable night’s sleep than a bed.
Positioning your arms so that they are elevated through the night is a good idea if you had lymph nodes removed – a stack of pillows under each arm is a good way to do this and is adjustable to your comfort level. You should have a surface (table, nightstand) within reach on which to put your pain medication and water so you can stay pain-free and hydrated. Set up your sleep environment before your surgery so that when you arrive home, you don’t need to make any further arrangements.
What to Wear
Wearing loose-fitting zip-front or button down shirts, dresses or robes until you can comfortably raise your arms above your head will allow you to dress and undress without overextending your arms. This may take a week or longer. Many women say their husband’s work or flannel shirts worked well for them. You can also purchase special post-surgical robes.
You will likely be sent home from the hospital in a surgical bra, which is a loose fitting soft cotton bra that serves two purposes: to protect the surgical site (you can use “fluff dressings” to pad and protect your chest from accidental impacts) and to hook your surgical drains to (you can just use safety pins). Alternatively, you may want to use a pocketed apron, or purchase a special garment for holding your drains. These come in various designs, from belts and neck straps, to stick on pockets, to robes with integrated drain pockets.
You may be given a compression bandage or garment, or told to purchase one – or you may be told to avoid compression. Follow your surgeon’s specific instructions about compression.
Things to Discuss with Your Surgeon
Some common problems women experience during their surgical recovery can be prevented or mediated by proper planning. It’s worth taking the time to discuss these issues with your surgeon, particularly if you have experienced similar issues in the past.
Your Desired Aesthetics. This is your body, and your choice. Make sure you feel comfortable that your surgeon understands your expectations for how your chest will look after the surgery. What incision pattern will your surgeon be using? How will they ensure a smooth flat contour? Visit the Going Flat Guide for a complete list of questions and more information.
Surgical Adhesives. Some women have skin that is reactive to surgical tape or adhesives – if your surgeon is aware of this, they can use alternative products known to be less likely to irritate your skin to close and dress your wound(s).
Anesthesia. If you know that you tend to experience nausea from general anesthesia, your surgeon may be able to prescribe a scopalamine patch as a preventative or take other steps to minimize the risk that you’ll experience nausea.
Narcotic Painkillers. If you have had nausea or other adverse reactions to narcotic painkillers before, your surgeon should be able to prescribe an anti-nausea drug (ex. Zofran) or an alternative type of pain medication regimen. There may also be options for anesthetic pain management.
Scar Management. Some people’s bodies react to wounds, including surgical wounds, by forming a hypertrophic or “keloid” scar. Most scars lie flat, but these scars are raised. Hypertrophic scars may flatten over time, whereas keloid scars are more pronounced and do not flatten over time. The good news is that this type of scarring can be reduced or prevented by using silicone sheets and/or taping to reduce skin tension (source). Scars can also be treated after they’ve formed, but prevention is preferable. People with darker skin tones are particularly prone to this type of scarring. Note: while plastic surgeons are usually familiar with aesthetic scar management, breast and general surgeons may not be, so you may need to request a referral (either to a plastic surgeon, or a dermatologist).
Physical Therapist Referral. If your health insurance requires a referral for you to see a physical therapist or rehabilitation specialist, ask your surgeon for a referral. Having a plan in place will help you get the care you need, when you need it. Note: a prescription for PT does not have to come from the surgeon or a cancer doctor – it can come from any MD (physician), NP (nurse practitioner) or PA (physician’s assistant). Check with your insurance company for their specific referral requirements.
Mastectomy is an amputation. Amputation is well known to affect physical function, sensation and body image (source). This is true regardless of your reconstructive choice (source). As with the loss of any body part(s), you will probably experience a grief process.
There will be an adjustment period after your mastectomy in which you will have to reorient yourself physically, mentally and emotionally to your new body. It is critical to have a support system as you navigate your recovery. That support can come from friends, a partner(s), family members, other patients, healthcare professionals, or some combination.
While a Facebook peer support group can’t replace your surgeon or mental health professional as a source of information, it can be helpful to crowdsource when you have questions about “is this normal?” Fabulously Flat, Fierce Flat Forward and Breastless & Beautiful are just a few examples of such groups. National organizations like After Breast Cancer Diagnosis (ABCD), SHARE Cancer Support and the Breast Cancer Resource Center also offer phone & video conferencing peer support groups.
If you think you might want to talk to a professional to help you cope, look for a therapist who specializes in treating oncology patients. CancerCare’s Hopeline [800-813-HOPE (4673)] is a great place to start. You can also search for an oncology social worker near you using the Association of Oncology Social Work’s online tool. You can also find local resources with Triage Cancer’s search tool, Cancer Care’s search tool, or contact your national cancer society [American Cancer Society] [Canadian Cancer Society].
Memorializing Your Breasts
You may want to consider memorializing your breasts before your surgery. Then after your mastectomy you will have something tangible with which to remember and honor your previous breasted body. Here are a few ideas, sourced from breast cancer survivor-created lingerie company AnaOno and life coach and breast cancer survivor Melissa Eppard:
- Photos. Photos of your breasts can help you remember them after they’re gone and play a role in supporting you through your grief and healing process. You can take intimate photos either by yourself or with a partner. Or, you can have professional photos taken – there are many photographers who specialize in boudoir, with options for all different styles and preferences. Peruse Instagram or Pinterest to gather some “inspiration” photos that you like to show to your photographer.
- Write a letter or journal/poetry about your breasts. Or, address your letter TO your breasts – some people find a sense of peace in thanking their breasts for what they’ve done for them and “letting them go.”
- Hold a farewell ceremony or celebration with friends and/or family. It can be as lighthearted as making a silly cake and enjoying the company and support of loved ones, or as solemn as you prefer. Some people have a special spiritual or religious practice, or meditation routine, that helps them process their feelings.
- Make a paper mâché or plaster cast of your breasts or torso, or have one professionally made, that can be turned into a sculpture you can keep.
Some women don’t feel inclined to do any of these things, and that’s ok too – preparing emotionally for your mastectomy is a very individual process and you know what’s right for you.
Some articles and inspiration:
- Pre-Mastectomy Self Love Tips (AnaOno)
- How One Woman Celebrated Her Breasts Before A Mastectomy (SELF, 2015)
- Cancer patient has plaster cast of her chest made before having mastectomy (DailyMail UK, 2014)
- Keep a Breast’s Treasured Chest (KeepaBreast.org)
- The Unique Way I Chose to Honor My Breasts Before My Double Mastectomy (HuffPost, 2017)
- Breast Cancer Boudoir (CBC News, 2020)
- A Conversation with Boudoir Photographer and Breast Cancer Survivor Jen Rozenbaum (Westcott University)
- Breast cancer survivors’ unique art therapy (AP News, 2016)
- Beyond Pink: Pre and Post Mastectomy Photos (Becky Yee Photography)
- Why Boudoir Changes Lives (Queensberry)
- A Young Woman Poses for Tasteful Boudoir Photos Days Before Double Mastectomy (Smithsonian Magazine, 2016)
- Woman documents breast cancer journey through boudoir photography (ABC7NY, 2019)
- My pre-mastectomy boudoir photo shoot (Fit is a Feminist Issue, 2015)
- Pre Mastectomy Boudoir Session San Diego (Debra Alison Photography)
- Thanks for the Mammaries! 27-Year-Old has Surprise Leaving Party to Say “Bye-Bye Boobs” Before Double Mastectomy (StoryTrender)
- Woman fighting cancer throws goodbye party for breasts before double mastectomy (ABC News, 2017)
- My boobs had to go – so I gave them a farewell party (BBC News, Scotland, 2020)
- Bye Bye, Boobies… a farewell on the eve of my double mastectomy (Medium, 2017)
After your Surgery: What to Expect
You should be given post-op instructions when you’re sent home from the hospital. Read through these instructions carefully and call your surgeon’s office if you have any questions. The following information is a general overview for patients preparing to undergo a mastectomy, and is not intended to be exhaustive or to be a substitute for your medical provider’s instructions.
Some patients experience almost no pain after their mastectomy. Others experience a lot of pain and even chronic pain long after they’ve healed from the surgery. Remember that mastectomy is an amputation – your body will need rest & proper hydration and nutrition to heal. Factors that influence how long your recovery period will be include overall health, prior strength & flexibility, prior injuries, extent of surgery (whether you had muscle and/or lymph node removal), and development & severity of lymphedema.
Your surgeon will most likely send you home with prescription pain medication to manage any post-surgical pain. They may advise you to stick to a dosing schedule of over-the-counter painkillers (ex. Tylenol, Ibuprofen), either to supplement the prescription painkiller, or to rely upon for primary pain management.
You may find that when you are first discharged from the hospital, your surgical anesthetic or nerve block is still in effect to some degree – be sure to stick to your doctor’s recommended dosing protocol to avoid experiencing breakthrough pain as the anesthetic wears off. If you experience severe nausea, constipation, or other unmanageable side effects from your pain medication, call your surgeon for advice. He or she may have other drugs that will work better, or anti-nausea or other medications for you to add to your regimen to counteract the side effects.
Most often, mastectomy patients are discharged from the hospital with one or more surgical drains installed. These are devices that prevent fluid from accumulating at the surgical site to promote proper healing. The drain is composed of a flexible, porous plastic strip that lies under your skin along the surgical site, a clear length of tubing that exits your skin, and a flexible bulb at the end that when depressed and stoppered produces a sealed system with a light vacuum. Maintaining this vacuum facilitates fluid drainage and helps to prevent infection.
Recording Output. Follow your surgeon’s instructions for drain care and management. You will probably be asked to record the drain output, which is the volume of fluid collected, so that your surgeon can monitor your healing and decide when to make the call to remove the drains. You will be instructed to “strip” the drains regularly to clear any blockages and keep them working properly. Stripping involves pinching and sliding your fingers down the tube to clear any obstructions; you can use an alcohol wipe to lubricate the outside of the tube. Alert your surgeon to any sudden or drastic changes in fluid output as this could indicate a blockage or a brewing infection.
Discomfort. Drains can be uncomfortable. While you probably won’t be able to feel the part of the drain that’s under your skin, the tube exiting your body is stitched to your skin at the insertion site to keep the drain in place. This stitch can pull and become irritated, especially when you move your arms. One trick is to hold the drain tube up and tape it to your skin to relieve the load on the stitch. Make sure you store your drain bulbs (in an apron or shirt pocket, pinned to your surgical bra, etc.) so that they aren’t pulling on the tube. Keep an eye on the insertion site – if you notice increased redness, swelling, warmth, or discharge, or if you have any other concerns, call your surgeon’s office.
Removal. Your surgeon will remove your drains when they judge it to be appropriate (typically within 1-2 weeks, but can be much longer). This is a simple in-office procedure in which the stitch holding the drain tube to your skin is removed, and the drains themselves are manually removed by quickly pulling them out through the insertion site. A light bandage is then placed over the (very small) wound. Follow your surgeon’s instructions for wound care to avoid infection and other healing problems. Drain removal is not usually painful, but there are exceptions to every rule. Speak with your surgeon if you’re anxious or concerned.
Note: a few surgeons use a technique called “quilt stitching” which largely avoids the need for surgical drains and has been associated with a reduced risk of seroma. This is a somewhat advanced technique that takes more time in the operating room. Other surgeons employ tissue sealants instead of surgical drains, but again, this is uncommon. If you have questions about your drains (or lack of drains), call your surgeon.
Things You May Notice As You Heal
When in doubt, call your surgeon’s office. Better safe than sorry. Read your discharge instructions for details about when to call immediately vs. less urgent matters.
Common things women have reported noticing after mastectomy that they didn’t expect:
- blue tinged urine the first day after surgery – this is your body clearing the dye used to assist in identifying which lymph nodes to remove
- slight initial redness and/or some bruising around incisions/drains
- the odd stitch being “spit” (working its way out through the skin)
- pinkish red to straw colored fluid and “stringy” material in the drains
- numbness across the chest and under the arm where nodes were removed
- “zaps” and phantom itching (as nerves damaged by the surgery begin to heal)
- some soreness, especially where lymph nodes were removed under the arm
- a general feeling of tightness across the incision area (“iron bra”)
- restricted range of motion of the arms – this should improve over time
- aesthetic issues: concavity where the breasts were removed, more pronounced belly contour (previously “hidden” under the breasts)
Call your surgeon if you observe or experience any of the following symptoms:
- Any change at all that concerns you. Follow your intuition – when in doubt, call your surgeon. While many rashes, swelling, color changes and lumps are harmless and will resolve on their own, some can indicate serious complications like infection, tissue necrosis, or cancer recurrence. Occasionally, a small hole will appear along a mastectomy incision line because a stitch has released the edges of the wound. If you notice these or any other changes on or around your incisions that concern you or that you’re not sure about, contact your surgeon.
- Uncontrolled, severe or worsening pain. Some soreness and discomfort is to be expected after a major surgery, but uncontrolled pain, severe pain, or pain that is worsening over time should be reported to your surgeon. A minority of mastectomy patients do experience chronic pain that requires ongoing management, called post-mastectomy pain syndrome (PMPS). This is a result of the mastectomy itself, not related to your reconstructive choice.
- Signs of infection. Redness or warmth in the skin, increased swelling, discharge or bad odor from the incision, sudden increase in drain output, cloudy drain output, fever, chills or unusual fatigue are some of the common signs of infection (source). An infection is more likely to occur the longer you have the drains in. If this happens, you may need oral antibiotics or, in more serious cases, a stay in the hospital for intravenous antibiotic therapy. Alert your surgeon immediately if you suspect infection.
- Bleeding. It is possible to have a bleeding problem at the surgical site. While minor bleeding will usually resolve on its own, major bleeding or bleeding that persists can be serious. If your drain output has been pinkish or clear and then suddenly becomes bright red, or if you have any reason to suspect bleeding, notify your surgeon immediately.
- Seroma. After your drains have been removed, you may experience an accumulation of fluid within the mastectomy pocket. A small amount of fluid may not be noticeable, but a large amount will “slosh around” and you may be able to see a wave-like motion of the skin when you tap it. This is a seroma. Seromas usually resolve on their own within a few weeks, but on occasion they can persist for much longer. Notify your surgeon if you think you might have a seroma. Treatment usually involves painless needle aspiration in office, but persistent seromas may require additional treatment.
- Skin Irritation. You may experience an uncomfortable skin reaction (pain, rash, blistering, etc.) to the surgical tape or adhesives used to close and dress the wound. This is more likely to happen if you have a history of reaction to Band-Aids, paper tape, etc. Let your surgeon know in advance so they can minimize the use of these materials. If you do suspect that your skin is reacting to the tape, let your surgeon know as soon as possible.
- Lymphedema. About 20% of mastectomy patients who had lymph nodes removed (or radiated) develop lymphedema, often within the first couple of years. This is swelling in the arm or hand and sometimes in the chest wall that can be very uncomfortable and can worsen over time, especially if left untreated. It happens because your lymphatic network was damaged by surgery and scarring, causing your arm to have trouble clearing fluid. While sometimes lymphedema that develops shortly after surgery will resolve on its own, be sure to call your surgeon if you experience any of the following common lymphedema symptoms at any time:
- visible swelling in the arm, hand, breast, or chest wall
- a sensation of heaviness, achiness, or tightness in the arm
- easy fatigue of the arm
- pain in the arm or trouble moving joints
- Cording. When your network of axillary lymph nodes is disrupted or damaged, which happens with both surgery and radiation, scar tissue can form along the remaining lymph network channels. This scar tissue is inflexible and can become quite thick, producing a “cord” or cords that can be painful and restrict your arm movement. Sometimes the cords can even be visible under the skin. This condition is called “cording,” or “axillary web syndrome” (AWS). If you experience tightness and/or pain that restricts movement in your arm and gets worse over time, or if you think you see cords appearing under your arm, alert your surgeon. He or she may be able to refer you to a physical therapist for treatment.
Stretching to Regain Your Range of Motion
As your surgical site heals, scar tissue will inevitably form between the mastectomy flap (that’s the skin which used to cover your breast tissue), and the chest wall. These are called “adhesions” and can restrict your mobility and/or cause pain. Light stretching exercises can help prevent adhesions from forming, maximizing your range of motion while minimizing exertion.
You may find that you can’t raise your arms very far up at first, and that’s okay. Don’t push yourself too hard or do anything that hurts. Your progress may seem slow, but over several days to a week you should have noticeable improvement. If you find that you’re not making progress, alert your surgeon. They may be able to refer you to a physical therapist.
Oftentimes, your discharge instructions will contain a list of suggested exercises. If not, here are some helpful resources:
It’s important to stay active during your recovery to maintain your overall fitness and well-being. You’ll need to choose activities that don’t require use of your arms – most people find the easiest way to manage this is by taking short walks throughout the day. You’ll be able to walk comfortably for longer periods as your recovery progresses, so don’t be discouraged if you’re easily fatigued at first. When your surgeon has cleared you to resume normal activities, you can add other exercise elements into your routine. More about that here.
Showering & Dressing
Showering. Carefully read through your discharge instructions to find when your surgeon wants you to resume showering. Typically, this will be 24 to 72 hours after you get home. When you shower, you will need a lanyard or necklace on which to hang your drains. Be gentle with your chest – your goal is to keep your skin clean while minimizing any damage to or irritation of the delicate tissues as they heal. When dressing, be careful not to overextend your arms or snag your drain tubes – wear zip front or button down tops to avoid raising your arms.
Compression. Some women, whether they have PMPS or just minor ongoing or periodic discomfort after their surgery, find that they feel more comfortable with light compression over their scars – i.e., a fitted tank top or athletic compression shirt. Others find loose fitting clothing to be more comfortable. Ask your surgeon about compression, and do what feels best for you!
Moving Forward: Now What?
Physical Rehabilitation & Exercise
Staying active and exercising regularly will help you to feel your best and reduce your risk of developing lymphedema in addition to potentially reducing cancer recurrence risk. This is unfortunately an area of post-op care that doesn’t get enough attention. Ask your doctor about beginning an exercise program that’s right for you, particularly if you’ve not been very active or athletic before – and get a referral to a physical therapist if necessary.
The UCSF Department of Physical Therapy & Rehabilitation Science also has an excellent booklet on this topic that has guidelines specifically designed for cancer survivors, including suggested exercises, here. You can also check to see if your local YMCA participates in the LiveStrong program, which provides free personal training for cancer survivors.
While many mastectomy patients recover full range of motion and resume normal activities on their own, there are major benefits to establishing a relationship with a physical therapist (PT) to assist with your surgical recovery. A PT with oncology experience will be the best fit for your post-mastectomy rehabilitation needs. Ask your surgeon for a physical therapist recommendation, or look for a local PT using the search tool provided by the American Physical Therapy Association (APTA).
When your surgeon has cleared you to resume regular activities (often around 6-8 weeks), you can begin a rehabilitation program to regain your pre-surgery strength, mobility & overall fitness. If you’re having lingering discomfort, tightness, or restricted strength or range of motion in your chest or arms, a physical therapist can help you with targeted exercises, scar massage, lymphatic drainage massage, pain management, and more.
It’s not unusual for your post-mastectomy chest to feel tight – like an “iron bra.” This is caused by scar tissue forming as your chest heals from surgery, and it’s from the mastectomy itself, not from going flat. Moving the tissues both through stretching and massaging the area can help to lessen the feeling of tightness.
Most surgeons will clear you to begin gentle scar massage after a month or two. It’s important to know that tissue maturation (growth) and radiation fibrosis (scarring) can take several years to stop tightening – so it may be necessary to continue your stretching program for some time to maintain your range of motion. A physical therapist can also help you with scar massage and other treatments tailored to your specific needs.
To massage your scars, use a mild lotion or oil. Stroke both in the direction of the scar (sideways) and also across the scar (up and down), spending a minute or two, several times a day (source). Dr. Waltke has a great video on mastectomy scar massage:
Lymphedema Risk Reduction
Unfortunately, if you’ve had lymph nodes removed, you will always be at an elevated risk of developing lymphedema. The good news is that there’s a lot you can do to reduce your risk:
- maintain a healthy weight
- stay active with regular exercise
- return your arms to full strength and mobility
- protect your skin from injury and infection
Stay alert and call your surgeon immediately if you notice any of the following:
- any sign of infection in the hand or arm – redness, pain, warmth, swelling
- any visible swelling in the arm, hand, breast, or chest wall
- a sensation of heaviness, achiness, or tightness in the arm
- easy fatigue of the arm/hand
- pain in the arm, or trouble moving joints in the arm/hand
- any other change in the arm/hand which gives you cause for concern
You may have heard to avoid blood draws on your affected arm, to wear a compression sleeve preventatively when flying, etc. In fact, the research now shows that those things haven’t turned out to be necessary for lymphedema prevention. Note: if you already have lymphedema, this does not apply to you. Always speak with your doctor about your specific medical situation. Here’s what Dr. Leslie Waltke has to say about lymphedema precautions:
There are a variety of treatments for lymphedema, from self-massage and compression to advanced microsurgery. If you develop lymphedema, ask your surgeon for a referral to a specialist to ensure optimal care. The Lymphedema Association of North America (LANA) has a directory of certified lymphedema therapists, and the American Physical Therapy Association (APTA) has a directory of licensed physical therapists which you can filter for oncology specialty.
Most insurance plans are required to cover the cost of specialists, compression sleeves (which are garments that are worn on the at-risk arm) and other treatments for lymphedema. For further information on lymphedema prevention and management, the UCSF Department of Physical Therapy & Rehabilitation Science has an excellent video resource here.
Managing Chronic Pain & Functional Problems
Lasting pain, weakness, or limited mobility is not “normal.” Some soreness and discomfort is to be expected after a major surgery, but uncontrolled pain, severe pain, or pain that worsens over time should always be reported to your surgeon. And if you experience weakness or limited mobility that does not get better – or gets worse – over time, get a referral to see a physical therapist.
Post-Mastectomy Pain Syndrome. You should know that a minority of mastectomy patients do experience chronic nerve pain that lasts longer than three months after surgery and requires ongoing management. This is called post-mastectomy pain syndrome and is a result of the mastectomy itself (it’s not related to your reconstructive choice.) If you find you’re experiencing this type of pain, ask your surgeon for a referral to pain management specialist.
Adjusting to Living Flat:
Body Image, Sexuality, Fashion, Tattoos, Prosthetics & More
As with any major change to your body, there will be an adjustment period to living flat after mastectomy. Head over to our Living Flat page to learn more about how to find community support and learn more about body image & sexuality, prosthetics, flat fashion, mastectomy tattoos and more.
Frequently Asked Questions (FAQ)
What’s the difference between a breast surgeon and a plastic surgeon?
Typically, a breast or general surgeon will perform your mastectomy. A plastic surgeon may or may not be present to ensure an optimal aesthetic result. All surgeons are first trained in general surgery, which involves training for common therapeutic surgeries (surgery to treat a medical problem). A breast surgeon has completed additional training in breast cancer surgery, while a plastic surgeon has completed additional training in aesthetic (also called cosmetic), and sometimes specifically in reconstructive, surgery. You may also hear the term surgical oncologist – these surgeons have completed additional training in surgical treatment of cancer.
Do I really need to see a physical therapist?
It’s prudent to do so if at all possible. Research shows that at least one in ten mastectomy patients will experience persistent arm/shoulder range of motion, weakness or pain problems which affect their quality of life, and about one in five will develop lymphedema. The more extensive your axillary node removal, the higher your risk of developing functional problems and lymphedema. Other risk factors for lymphedema include higher BMI and having undergone radiation therapy. The higher risk you are for developing these problems, the more important it is to see a physical therapist. Evaluation and management of these problems is their specialty, and seeing them before your surgery (or as soon as possible afterwards) is the best way to prevent them from developing, or from getting worse.
Is physical therapy covered by insurance?
Most health insurance plans cover post-surgical physical therapy as an “essential benefit.” Check your insurance policy to see if you need a referral from your surgeon, or if you can see a PT without a referral. Keep in mind that your usual co-pays and deductibles will still apply. (More)
How long will I be out of work recovering from the mastectomy?
This is highly dependent on the individual patient, and of course the extent of surgery, whether or not you experience any complications, etc. If you have a desk job and recover quickly, you could be back to work in as little as two weeks. If your job involves lifting, it could be 4-6 weeks or longer. And if you experience complications, that will extend the timeline as well. (More)
How long will I have to stay in the hospital after my mastectomy?
This varies a bit, but it’s typically a short stay of less than three days. Your surgeon may be able to give you a more specific timeframe. (More)
I want a double mastectomy, but my surgeon doesn’t want to remove my “healthy” breast. What should I do?
Women who choose double mastectomy do so for a variety of perfectly valid reasons, and the Women’s Health and Cancer Rights Act of 1998 protects your right to make this choice. If you feel your surgeon isn’t listening to you or if you disagree with their rationale, you have the right to seek a second opinion.
Many surgeons view the increase in double mastectomy rates in recent years as a public health problem, and worry that their patients may incorrectly believe that removing their “healthy” breast improves their prognosis. You may also have co-existing medical problems that put you at a higher risk for complications (a double mastectomy is a more extensive surgery than a single mastectomy), and the COVID-19 pandemic may affect the risk calculation as well.
When I asked for an aesthetic flat closure, my surgeon didn’t know what that was.
Aesthetic flat closure is a new term, and some surgeons aren’t yet familiar with it. That doesn’t mean they can’t give you a nice flat result, but you’ll want to ask specific questions about HOW they will get a flat result in your specific case. If you sense pushback or hesitation, ask if they would consider bringing on a plastic surgeon, or consider a second opinion. More here.
Will I be able to wear prosthetics home from the hospital?
Most women find prosthetics too uncomfortable to wear until they have healed for several weeks or months. Ask your surgeon about your options if this is important to you. More about prosthetics at our Living Flat page.
Will people stare at me if I don’t wear prosthetics?
Most women who have gone flat after mastectomy report that no one really seems to notice, or if they do, the comments are more along the lines of “have you lost weight”? There’s no universal experience, of course. If you feel more comfortable wearing prosthetics, that’s ok! Check out our Living Flat page for more fashion tips and inspiration.
What causes “phantom itching” and how long does it last?
When the breast tissue is removed during the mastectomy, nerves are severed. It’s the healing of these nerves that causes the sensation of itching in the amputated breast. Many patients report the itching peaks around the 2-3 month mark after surgery and then fades away, but it’s variable. For relief, you can experiment with gentle pressure, warm or cold compresses (use caution – numb areas of skin are easily burned/damaged this way), stretching, massage, and tapping. If the sensations are severe or long-lasting, speak with your surgeon.
Why does my chest look concave after my surgery?
A mastectomy for breast cancer involves complete removal of all breast tissue, and afterwards, the underlying structures that are revealed are frequently concave to some degree. This is not something the surgeon can see beforehand and plan for. Nor does the surgeon know exactly how far down they’ll have to go to remove all of the cancer. Tissue rearrangement can counteract initial concavity, but not all cancer surgeons are trained in tissue rearrangement. Fat grafting may be an option to consider. That’s a separate procedure offered by plastic surgeons.
How long do I have to wait to get a mastectomy tattoo?
Ask your surgeon for directions. Most will suggest waiting a year or longer before getting a tattoo over the mastectomy site. You’ll need to be completely healed from surgery and any radiation treatments first. For more about mastectomy tattoos, visit our Living Flat page.
What do I do with all of my old bras?
It’s up to you! Some women donate them to local women’s shelters or to a nonprofit like I Support the Girls. Revising your wardrobe for your new flat body is a process that looks a little different for everyone, so if you want to hang on to some or all of your old bras, that’s ok too.
Where can I find more information about mastectomy and breast cancer treatment?
The nonprofit organization BreastCancer.org is the premier source of medically reviewed information about all things related to breast cancer.
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Adhesion – scar tissue that forms between the mastectomy flap and the chest wall which may restrict range of motion and/or cause pain (more)
Axillary dissection – surgical removal of some or all of the axillary lymph nodes (more)
Axillary lymph nodes – the lymph nodes under the arm
Axillary web syndrome (cording) – a condition caused by lymph node dissection where scar tissue forms along the lymph network channels after axillary dissection, resulting in pain, range of motion restriction, and sometimes a “cord” or cords visible under the skin (more)
Board certified – a surgeon who is board certified meets the standards for surgical specialty knowledge and practice set by the relevant professional society
Breast tissue – the fibroglandular tissue of the breast, including lobes and ducts (more)
Breast surgeon – a general surgeon specializing in surgical treatment of breast disease (more)
Certified lymphedema therapist (CLT) – a medical professional or paraprofessional (usually a physical therapist) who has completed a training course that is specific for the treatment of lymphedema (more)
Chest wall – the bone, muscle and other tissue that comprises the front of your torso and largely determines the contour you see after the mastectomy
Compression sleeve – a flexible fabric sleeve with a compression gradient (tighter at the wrist than at the shoulder) worn on the arm that encourages lymph fluid clearance (more)
Concavity – a hollowed out, or “scooped out,” appearance commonly seen at the surgical site after a mastectomy without conventional breast reconstruction
Contralateral prophylactic mastectomy (CPM) – removal of the unaffected breast at the time of a mastectomy for unilateral breast cancer
Cording (axillary web syndrome) – a condition caused by lymph node dissection where scar tissue forms along the lymph network channels after axillary dissection, resulting in pain, range of motion restriction, and sometimes a “cord” or cords visible under the skin (more)
Defect – a term used by surgeons to describe an imperfection (or discontinuity) in the contour (shape) of the surgical site (ex. “dog ears,” concavity, etc.)
Dog ears – can refer to one of two types of defects: excess tissue left over under the arms after a mastectomy, or a “peak” of skin at the end of an incision (vs. a flat scar)
Drains – (surgical drains, JP drains) temporary implantable medical devices used to promote wound healing through continuous removal of excess serous fluid at a surgical site (more)
Fellowship trained – a surgeon who has completed a formal program of additional surgical training to become a specialist in the area the fellowship focuses on
Gauntlet – a flexible fabric glove with a compression gradient that encourages lymph fluid clearance from the hand (more)
General anesthesia – a combination of medications (intravenous drugs and inhaled gasses) that put you in a sleep-like state before a surgery or other medical procedure so that you do not experience pain or discomfort during the procedure (more)
General surgeon – a surgeon trained in general surgery
Hematoma – an accumulation of blood under the skin, most frequently at the surgical site
Hypertrophic scar – scar tissue which is somewhat thickened and raised but may flatten over time (more)
“Iron bra” – a feeling of extreme tightness across the across the ribs and chest post-mastectomy
Keloid scar – scar tissue which is thickened and raised and does not flatten over time (more)
Lumpectomy (Partial Mastectomy) – the surgical removal of the tumor(s) along with some (not all) of the surrounding breast tissue to treat or prevent breast cancer (more)
Lymphedema – swelling (edema) resulting from damage to the lymphatic system (more)
Mastectomy – the surgical removal of all breast tissue including the nipple to treat or prevent breast cancer (more)
Mastectomy flap – the skin which used to cover your breast tissue before the mastectomy
Mastectomy tattoos – a tattoo that is drawn on top of the mastectomy site, usually to cover mastectomy scars (more)
Narcotic painkillers – opiod drugs used for relief of short-term, intense pain such as that occurring immediately after surgery (ex. hydrocodone, oxycodone) (more)
Nerve block – the injection of local anesthetic close to a targeted nerve or group of nerves to lessen pain (more)
Nipple-Sparing Mastectomy – the surgical removal of all breast tissue, but preserving the breast skin and nipple, to treat or prevent breast cancer (more)
Partial Mastectomy (Lumpectomy) – the surgical removal of the tumor(s) along with some (not all) of the surrounding breast tissue to treat or prevent breast cancer (more)
Phantom itching – the sensation of itching from a missing (amputated) body part
Physical therapist – a medical professional specializing in treating disorders of the human body primarily by physical means to improve physical function and manage pain (more)
Plastic surgeon – a general surgeon specializing in aesthetic and/or reconstructive surgery (more)
Post-mastectomy pain syndrome (PMPS) – chronic nerve pain that persists for more than three months after mastectomy (or lumpectomy) (more)
Prophylactic mastectomy – removal of the breasts to reduce the risk of developing breast cancer for patients at an elevated risk due to genetics or family history’
Prosthesis (prosthetic) – an accessory shaped like a breast that is worn under clothing to produce a breasted appearance after mastectomy (more)
Range of motion – the extent of movement of a joint (more)
Sentinel node biopsy – a diagnostic procedure where a small sample of lymph nodes is removed and tested for the presence of breast cancer cells to determine cancer stage
Seroma – an accumulation of serous fluid under the skin at a surgical site where tissue has been removed (more)
Skin-Sparing Mastectomy – the surgical removal of all breast tissue including the nipple, but preserving the breast skin, to treat or prevent breast cancer (more)
Spit stitch – a surgical stitch that has worked its way up through the skin and appears as a small bump before breaking through the surface (more)
Steri-strips – specialized adhesive bandages used to close surgical incisions (more)
Surgical oncologist – a general surgeon specializing in cancer surgery (more)
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