Massage for Post Mastectomy Scarring
Mastectomy is often a necessary treatment for cancer or prevention of cancer. It is common for scar tissue to form post surgery. The amount will vary depending on how the surgery was performed: how much tissue needed to be removed and especially how the surgeon closed the incision. Scarring is also dependent on how your body reacts to wounds and healing. Massage can be very helpful in decreasing the effect of the scar tissue if performed soon after the surgery, however it can also be used to release the scarring after it has become a post-op problem.
The most common incision is oblique across the nipple line and continuing up into the axilla. It has varying lengths depending on how many lymph nodes need to be removed and how much lateral breast tissue is present. The larger the incision the more structures can be involved with the scarring. The surgeon has to cut through the skin and superficial fascia, excising all of the fatty and glandular breast tissue and the fascia that creates the structure of the breast.
In cases where there may be spread of the cancer, the surgeon will also remove some or all of the axillary lymph nodes – which then affect the axillary fascia and muscles. Our bodies are built with multiple layers between the skin and muscle tissue and the layers are supposed to slide over each other independently. After surgery the incision site will often connect these layers forming a thick scar throughout the layers. There will be some patients who have a mastectomy and have no long-term problems due to their scarring.
The shoulder is a very complex and dynamic area and can be affected by scarring post mastectomy. Our muscles have an extremely important role of stability around this joint. There are many muscle groups that attach to the shoulder girdle and have different directions of pull. If one area becomes shortened or spasmed it will make the other areas work harder to counter the force in the shortened or spasmed direction. Then those secondary areas will also start to shorten and/or tighten in compensation to the original force. As you can imagine, this can become a domino affect until all of the muscle groups around the shoulder become shortened and rigid. Then you will see a frozen shoulder type of pattern. As scars form they tend to pull and twist into themselves, pulling in the tissues around them to the central scar area. Post mastectomy this force will pull the fascia of the anterior shoulder and the bony shoulder girdle down and forward. The anterior muscles will all shorten to this new resting length. Conversely the muscles on the back of the shoulder girdle will be stretched. Muscles do not like to be longer then their resting length, so they will contract to get the fibers back to the right length. Over time this chronic contraction will fatigue the muscles and they will start forming adhesions within the muscle. At this point the patient will feel varying degrees of pain and dysfunction in their shoulder complex. Often I have seen the patient complaining of pain in the back and top of the shoulder. They may feel a pull in the front of their shoulder in the scar tissue and even the pectoralis muscles may feel sore and tight. These mechanical changes will affect the range and function of the shoulder complex, so the patient will often note a change in her ability to perform daily activities.
The more scar tissue that has formed the more work will be required to release the layers. It is possible that there will always be some adhesions between the layers. Massage will bring a positive change to the scar itself and will also release that natural pulling of the surrounding fascia into the scar area. This will help to restore the shoulder complex to a healthier balance, function, and manage the symptoms arising from this imbalance. Here is a link to a great stretch for the anterior shoulder for someone with restrictions like scar tissue.
The healing of the breast area is complicated by whether or not radiation is required to fully treat the cancer. Radiation has many long-term affects on the tissue: the tissues become less elastic due to a diffuse scarring process, there is a long term local inflammation in the tissues treated that never resolves, lymphedema due to damage to the axillary nodes and lymphatic tissue near the breast causing swelling and poor drainage of the area, and changes to the skin post radiation which usually resolves post surgery, but could be a problem in areas with folds in the skin like the axilla or breast. These complications can affect how the massage can help the patient. If the tissue is less elastic and has chronic localized inflammation it will react differently to the treatment, so the results may not be as expected. Massage utilizes the inflammation process to re-align fibers in the tissue and muscle, when that process is abnormal it may not act the way it was supposed to. Further, even with a significant change with the massage, the long term effects of the radiation may over-time encourage the scar tissue and fascia to pull back and become a problem symptomatically again. In this case some form of semi-regular maintenance massage will help keep those long-term effects in check.
Working with a patient post mastectomy has many factors. How involved the scar tissue is? What compensations have formed already? Were there any parts to the treatment that could have changed the tissue and need to be considered during the treatment. What is the past history of this area: old injuries, repetitive work postures, etc? Along with these questions there are also many emotional factors. This is a sensitive area for most women. Having a compassionate registered massage therapist who can be respectful and also deal with all the physical after affects of a mastectomy can have a huge impact their quality of life.