Disclaimer: Below is a case report of top surgery (food for thought) and should not be considered medical advice. Post-surgical considerations were individualized for the patient and an explanation of the rationale for interventions is not complete.
One thing that I love about comprehensive breast cancer care is how transferrable many treatment principles and skills are to other patient populations.
At the end of 2022, one of my former pelvic physical therapy clients made the decision to have top surgery. Top surgery involves removing some or all of the chest or breast tissue (a.k.a. subcutaneous mastectomy) and/or loose skin for gender affirming and/or sensory needs. More recently, more patients, especially non-binary people, have been requesting variations of the traditional top surgery aesthetic which may involve removing less tissue and/or the nipples rather than having nipple grafts. This patient chose to leave some chest tissue, remove loose skin and the nipples. We will call them P (pronouns ze/zir; ze/zir are neopronouns, an alternative pronoun for he/she and his/her). Ze knew that I treat breast cancer patients and thought, "Maybe Susannah can help me." Ze was about a year post-cesarean section delivery, and very active (especially in partner acrobatics), but ze was concerned about how top surgery might impact zir ability to physically take care of zir baby and continue enjoying circus arts.
P reported a confusing array of post-op recovery guidelines from surgeons reported by patients on online top surgery patient forums. The directives for when to lift your arms overhead, resume daily activities, progress back to non-restricted exercise, and how long to wear a binder were extremely varied in answers (this is often true for surgical recovery for breast cancer patients as well).
As a physical therapist specializing in breast cancer rehab, part of what I do is provide post-op care for breast cancer patients. I understand the healing timelines for these procedures, how to optimize healing, and progress people back to optimal levels of function. Why couldn't post-mastectomy rehab skills apply to subcutaneous mastectomy for top surgery as well?
In my opinion, every person post lumpectomy, mastectomy, and reconstruction would benefit from even a few sessions of physical therapy, but most often, I get referrals to treat complications. These complications can include post-op pain, shoulder dysfunction, and lymphedema to name a few. I'm a much bigger fan of getting AHEAD of any complications with prevention measures and early intervention. Physical therapy can also help with post-op swelling, healing of the incision, fascial mobility, and aesthetics (improved appearance) after surgery. So, when P called me to see if I could help, I was very interested in applying my skills for breast cancer patients to top surgery in gender-affirming care. P was very concerned with how to restore zir full range of motion and ability to lift baby and weight as soon as possible. Ze was eager to avoid any complications by proactively engaging in prehab and rehab.
Immediate post-op healing…
Prior to going in for surgery, I sent zir patient education handouts 'Self-care after Mastectomy' and 'Mastectomy Immediate Exercises' from The Breast Bundle. Ze was surprised that zir common sense about what movements to avoid and which progressive movements were safe was not always accurate. Ze expressed much relief about having my guidance about how to safely stretch and move while healing without harming their incisions. Almost 2 weeks after surgery, P presented to my office for an initial evaluation and treatment. We removed the dressing; the incisions were well-healing, there was minimal post-op swelling, and no seromas or other post-op complications were detected. P reported feeling very sore with shallow breathing from 24/7 binding and noticed a hunched protective posture that was causing discomfort. I performed manual lymphatic drainage to reduce post-op swelling, used a cold laser called the LTU-904 to the incision for healing, reviewed post-op precautions, reinforced wearing the binder for seroma prevention, did some postural re-education, and got a little more creative with deep breathing techniques.
Lifting restrictions and protecting the incision…
Between the initial visit and the first full treatment session the next week, range of motion restrictions above shoulder height were eliminated and I gave the patient intermediate post-mastectomy exercises. P demonstrated 100 degrees of shoulder flexion on zir first attempt; the incisions were still well-healing, but tightness was felt and visually perceived at the lateral aspect of the mastectomy incision (a very typical presentation).
We began indirect myofascial work to the incision and surrounding fascia to get more mobility while respecting the integrity of the skin as it healed. We whipped out the ol' LTU-904 by RianCorp to support incisional healing and did a second and final round of manual lymphatic drainage before beginning soft tissue mobilization for improved shoulder range of motion.
It is important to note that a common reason for restricting the overhead range of motion after top surgery is for improved aesthetics; minimizing the width of scarring after surgery. A couple of things to consider, though, are the balance of scar tissue healing with shoulder health as well as the fact that people have a predisposition to scarring differently. We knew from P’s c-section scar that ze tends to have minimal scarring and zir priority was range of motion over aesthetics.
Furthermore, because of the athletic nature of this client who was asking about future progressions back to acrobatics, I chose a safe activity to demonstrate how surgery at a distal (far away) site can impact the strength of muscles that share fascial lines. Ze was quite surprised by how zir core strength was impacted with a simple manual muscle test and we went back to core stabilization basics. Ze was also quite relieved to get clearance for sleeping supine on zir back.
When things don't go quite as planned…
Hastily pulling a light plug out of the socket at a peculiar angle led to irritation, widening, and mild fluid buildup at the edge of zir right chest wall incision. Photos were shared with the plastic surgeon and a plan was put in place to support healing. It helps to have a rehab practitioner on hand to prevent complications like wound dehiscence and infection.
Having a team in place to support the patient and surgeon can improve communication and understanding, and reduce the wait time to see the surgeon and office visits with the surgeon. Regularly scheduled follow-up visits with a rehab provider also allow screening for complications that otherwise may go unreported. In addition to early screening and intervention, rehab practitioners also have conservative treatment techniques in addition to over-the-counter and prescription medications that can improve healing, improve surgical outcomes, and reduce the overall cost of medical care if complications persist.
I think of the in-between as an important transition time between initial post-op healing and full return to activity with mature scar formation. It's also a malleable time of healing opportunity that is hard to get back. During this time it is important to ensure that the scar heals in layers that can glide and move with each other. Rehabilitation can prevent scars from healing with the skin, fascia, fat, and underlying muscles adhering to each other. When connective tissue layers bind together, the range of motion in nearby joints can be restricted, fascia can become tight, and pain and functional deficits can ensue in the short or long term. One of my favorite rehab sayings is "the body tells a story."
Because P is also an acrobat, can we expect zir to return to high-level performance arts without a trained eye and exercise progressions? Let's take a handstand for example; handstands require:
good inverted posture to ensure stacking of the diaphragms for core control
proprioceptive awareness and balance with the ability to safely (intentionally or unintentionally) fall out of the handstand position
scapular stability and core strength to ensure proper form and prevent injury
mobility of the ribcage and excursion of the respiratory diaphragm to ensure deep core stabilization and pressure regulation to prevent injury
Surgery to the chest wall can:
change fascial length affecting surrounding joints
decrease the mobility of the chest wall and excursion of the respiratory diaphragm
alter timing, recruitment, and strength of muscles
Breast cancer rehab practitioner's assessment and treatment in the short term can improve incisional healing, posture, range of motion, strength (neuromuscular control), and proprioception to prevent injury and ensure a safe return to activity in the long term. (Again, improving surgical outcomes and alleviating future financial burdens to the patient and medical system).
Ze and I had a total of 7 sessions over a span of 8 weeks, and 11 weeks after surgery, you can see P with a giddy smile popping a handstand!
Would I recommend any person launch into a handstand 11 weeks after top surgery? No. It depends on the patient's prior level of function as well as the person's observance of post-op restrictions to protect the incision, compliance with progressive exercises, and individual exercise prescription to address whole-body strength and range of motion deficits to safely perform such a task.
P was a regular handbalancer right up until the day of surgery and followed zir surgeon’s directions and my suggested home exercise program carefully. Because of the nature of zir particular nonbinary top surgery, less tissue was removed from the chest wall which impacted zir healing timeline. Before we got here, we needed to address modifications to other activities of daily living such as P being able to lift their 10-month old baby safely. Oh, and can we just quickly address the necessity for the parent to mentally feel prepared to do this safely as well as the importance of being held for the child's development and attachment to the parent? Improving the quality of life is an important aspect of physical, mental, and spiritual health that makes being a rehab practitioner so rewarding and warrants consideration.
If you would like to learn more about how to treat breast cancer patients post-mastectomy as well as how to prevent and alleviate the MANY side effects of medical intervention for breast cancer, Check out our course "Breast Cancer Rehabilitation: Evaluation & Treatment". Registration ends by 8th of March.
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