May 2008: After Surgery: Short-term and Long-term Effects

Itching normal after mastectomy and reconstruction?

Question from Calico: Is it normal to have itchiness after bilateral mastectomy with reconstruction? It's been 2.5 yrs and it drives me crazy. It seems to be “inside,” no signs of abnormality outside, no redness etc...and it is on the good side too. Thank you.

Answer —Kristin Brill, M.D., F.A.C.S.: That itchiness is not uncommon. It may be nerve pain or sensation. You get the sensation of itchiness, almost like a phantom pain. It may be more nerve-related than anything truly real or skin related. It tends to disappear over time.

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Help with drain problems?

Question from Me: Hi! Good evening! My friend just had her operation and I think the drain is not working well. She would wake up soaked with blood from the drain. What do we do?

Answer —Kristin Brill, M.D., F.A.C.S.: The drain can become clogged. Sometimes little bits of debris or clots can clog the drain. There's a technique to strip the drain. She probably ought to call the doctor or a nurse and they can help with the clog in the drain. I would add it's not dangerous having it leak out from the skin; it's just more of a nuisance than anything.

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Lymphedema risk, healing time with sentinel biopsy?

Question from Lils: After having a lymph node removed, how long of a time does it take for the soreness to completely go away? Are cancer survivors who had a sentinel node biopsy susceptible to lymphedema?

Answers —Kristin Brill, M.D., F.A.C.S.: There will be swelling and lumpiness at the incision site at least for several weeks and into several months. Eventually, the swelling will go down and there will always be a little bit of tenderness at the scar tissue.

Linda Miller, P.T.: Women who have had sentinel node biopsy are at less risk to get lymphedema; it's about 10% to12% of incidents at this point. We do recommend that if you have sentinel node dissection that you still follow the lymphedema precaution list.

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Lymph fluid re-routed? Helped by physical activity?

Question from JPP: Does the body find a way to re-route drainage of lymph fluid after ALL lymph nodes are removed from under one arm? Does physical activity encourage this?

Answers —Linda Miller, P.T.: Yes, there are actually several different routes by which the arm drains. Not all of those drainage points actually go through the axilla. So there are alternative routes through which the arm can drain. Exercise and physical activity does increase lymphatic flow.

Kristin Brill, M.D., F.A.C.S.: It encourages other pathways to compensate for what was removed.

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Restrictions after surgery?

Question from Nan W: How does driving or lifting heavy things affect my arm or cause any kind of problems with the area where I got the surgery?

Answers —Kristin Brill, M.D., F.A.C.S.: You should be properly healed before lifting or extending to full range of motion. Once healing has occurred, we encourage strengthening and stretching exercises to get you back to your baseline as much as possible.

Linda Miller, P.T.: I think the key here is to get a gradual return to activity. Most women can return to the full function, but need to return gradually.

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Normal pain vs. warning signs in reconstructed breast?

Question from SIONA: I have had a mastectomy with immediate reconstruction 4 months ago. What are considered to be normal pains in the reconstructed breast, and what are warning signs?

Answer —Kristin Brill, M.D., F.A.C.S.: Occasional pains, sensitivity, or twinges at the reconstruction site are normal. Some of this is very individual, and some dependent on the type of reconstruction. With good physical therapy and post-op care it should be tolerable and improve over time. While we don't do imaging routinely on the reconstructed breast, we do examine the breast visually and with palpation to look for any issues with healing or any signs of recurrence.

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Squeezing, pectoral pain after mastectomy?

Question from JKO: Since mastectomy in 2006, I have muscle spasms in the pectoral muscle and pain along the incision area. I have lymphedema in my left arm and also truncal lymphedema. Also I have a constant squeezing like a boa constrictor squeezing under my ribcage area and it goes around my entire body. No one has been able to determine what causes the squeezing pressure, or the pectoral pain. Advice?

Answers —Kristin Brill, M.D., F.A.C.S.: At the time of mastectomy, the surgery extends down to the base of the breast, including the covering of the pectoralis muscle there. For many women, they notice increased sensitivity at the ribcage after mastectomy, particularly after implant placement. It's also common to see sensitivity at the rib with age with anyone. This is something called costochondritis.

Linda Miller, P.T.: Many women after reconstruction have had that tight chest wall feeling. A good stretching program that really stretches the pectoral muscles can give significant release.

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Bowling increases lymphedema risk?

Question from Ice Cream: Should I be concerned with getting lymphedema if I continue bowling in a league 3 games per week? I bowl right-handed and my right breast and nodes were removed.

Answer —Linda Miller, P.T.: Lymphedema is always a concern; however, lymph fluid moves with movement, so staying active is an important part of lymph management. The key is to be consistent, do proper warm-up and stretching prior to bowling, and don't dramatically change how much you bowl at any one time.

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No relief from tightness and pain after mastectomy?

Question from Patti: I had a double mastectomy August '05. I still have tightness and pain throughout the area. I have been through physical therapy, but no relief. Any suggestions? Thank you.

Answers —Kristin Brill, M.D., F.A.C.S.: The tightness and pain is probably secondary to scar tissue. Physical therapy is really the first line to address that. There are alternative methods to deal with chronic pain or tightness. Some include practices like yoga or acupuncture. Many women have had success with alternative treatments as well.

Linda Miller, P.T.: Any physical therapy may also need to include some deep soft tissue and scar tissue work. The therapist shouldn't be afraid to actually do aggressive soft tissue work if that's indicated.

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What is axillary web syndrome?

Question from Patti: Can you provide information on axillary web syndrome (AWS)? I had an occurrence almost 3 years after surgery -- a lumpectomy with removal of 3 or 4 sentinel nodes and follow-up radiation. There is very little information on the subject, and my doctor said it is not very common. Thank you.

Answer —Linda Miller, P.T.: It's not unusual to have axillary web syndrome, or post-operative cording months or even years post-operative. Often times it's precipitated by a sudden increase in activity, especially if you haven't been doing regular stretching, which a lot of women kind of stop doing as time goes on. The best way to treat it is to restart your general stretching, lifting the arm up over your head while keeping your elbow straight.

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Costochondritis, recurrence risk after mastectomy and implant?

Question from Maska: I had a mastectomy 9 years ago with a saline implant. I had DCIS with microinvasion and clear lymph nodes. After 9 relatively pain-free years, I'm now struggling with costochondritis, with pain under the implant and around to my back. I had an MRI and there was no sign of metastasis. Should I worry that this is a recurrence, and how can I deal with the pain?

Answer —Kristin Brill, M.D., F.A.C.S.: It's unlikely with DCIS 9 years ago that this is recurrent, but MRI is appropriate to evaluate for recurrence and also the integrity of the implants and surrounding tissues. Costochondritis is a common problem in women who have been affected by breast cancer and who have not. It acts up in a similar way to arthritis, so arthritis treatments may improve symptoms of costochondritis as well. You have the option of seeing a plastic surgeon to determine whether any alteration in the reconstruction or the implant will help.

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Shooting pains normal in breast area? Causes?

Question from MarieA: I am 4 1/2 years cancer-free after mastectomy of left breast and sentinel node biopsy. I had dose-dense chemo and radiation. I still get shooting pains at breast site and it takes my breath away sometimes. Is this normal and what causes it? Thank you.

Answers —Kristin Brill, M.D., F.A.C.S.: Sensitivity at the mastectomy site is common and can result from both discomfort at the scar and tenderness at the ribs. This is particularly true following post-mastectomy radiation. Stretching may help, as well as anti-inflammatory medications such as Motrin or Aleve, if you are able to take these medications.

Linda Miller, P.T.: I can't overemphasize the importance of continuing stretching long after you've had your breast cancer surgery, especially with mastectomy. The tendency will always be for that skin and pectoral muscle to tighten up, and so stretching 2 to 3 times a week may help relieve some of those long-term chronic symptoms.

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Fibromyalgia or Aromasin side effects?

Question from HKR: I have muscle and even bone pain. How do I know if it is fibromyalgia vs. side effects from Aromasin? Pains move from one place to another and worsen with cold and when tired.

Answer —Kristin Brill, M.D., F.A.C.S.: Bone and joint pain with any of the aromatase inhibitors is common. Typically, it's worse in the morning when getting up and beginning to move, and subsides with activity. Typically, it's symmetrical: for instance, in both knees or both hips, and sometimes in the long bones. For anyone who notices a new pattern of bone pain or ache (for instance, one pin-point spot that is new and doesn't seem to relent during the day or with anti-inflammatories), this may be something your doctor will investigate further. Still, this is likely to be arthritis or some benign cause.

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Cause of tingling, tightness in affected arm?

Question from JeanJ: How does one distinguish strange tingling, tightness sensations in the arm affected (especially underarm) from either the surgery, radiation, or anything more serious to be concerned about?

Answer —Kristin Brill, M.D., F.A.C.S.: Numbness and burning, tingling sensations from the armpit down to the elbow, especially the undersurface of the arm, is common after any sort of axillary surgery. For some women, this disappears after several weeks and for others, it persists more long-term. This is due to disruption or irritation of the nerves in the axilla that supply those areas. Typically, it is not a sign of any new problem. Any new sensations, though, particularly years out from surgery (meaning new pain or lumps) ought to be investigated.

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Fluid build-up normal years after surgery?

Question from Momof2: My friend had a lumpectomy 15 years ago. Recently she has been having fluid in the area where the lump was removed. Her doctor drained the site and removed scar tissue. The fluid returns within days. Is this normal? She is concerned that it fills up again and again. Her mammograms are fine and there is no pain. The doctor says not to be concerned but she is.

Answer —Kristin Brill, M.D., F.A.C.S.: Fluid accumulation or seroma is common immediately after lumpectomy, and can take up to a year or longer to resolve or be absorbed by the body. It's unusual to see fluid accumulate many years after surgery, and sometimes the doctor will drain fluid and even send the fluid for pathology evaluation. If the tissue has been re-excised, she can expect new fluid accumulation due to the recent surgery. Sometimes in this scenario, MRI is helpful to reassure the patient that it's all benign, post-operative changes.

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Long-term effect on skin from radiation?

Question from HR: What is the long-term effect on tissue that has been exposed to radiation treatments?

Answer —Kristin Brill, M.D., F.A.C.S.: Radiation has both short-term and long-term effects on tissue, so that initially we see redness and swelling with radiation. Then after many months, fibrosis or scarring begins to occur. Radiation also scars small lymphatics and blood vessels so that healing can be delayed and an increase risk of infection can exist in areas that have been radiated.

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Breast swelling normal after partial mastectomy?

Question from KHU: My mother-in-law had a partial mastectomy just over 1 month ago. She is typically a size B cup but the breast swelled to at least a size DD and may have only gone down to a D now. The bruising is getting a little better. Is this type of swelling normal? What should she do?

Answer —Kristin Brill, M.D., F.A.C.S.: The swelling is likely from hematoma, meaning blood and fluid collection, and is common after surgery even one month out. Eventually, depending on the size of the collection, the body will absorb this fluid and ultimately, she should be back to her pre-operative size. But some scarring may actually form, so there could be some mild alteration in size or shape.

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Info on post-mastectomy exercises?

Question from Sheree: I am a breast health navigator in Ft. Worth, TX. There seems to be little information on exercises post-mastectomy with the exception of the ACS booklet. Is your educational program available for use at other facilities? I have several patients who are frustrated with the lack of knowledge of what exercise routines or programs they should do post-mastectomy.

Answer —Linda Miller, P.T.: I have educated many facilities around the country with how to address post-operative complications after breast cancer. If you want to contact me directly, I have a fair bit of information I can provide you to disseminate to your patients. Programs sometimes need to be altered, depending on whether reconstruction, or which type of reconstruction, has been performed. That's one reason why just giving a protocol exercise program is difficult.

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Rubbing helps soften scar tissue?

Question from Arlene: I had surgery for a malignant tumor exactly 1 year ago. The surgeon went in three times. I have a big indentation and a lot of scar tissue. Can I continue to rub it to see if it gets any softer? The surgeon said I should have rubbed it from the beginning but failed to tell me that after my first surgery. Great, huh?

Answer —Kristin Brill, M.D., F.A.C.S.: It sounds like you've had re-excision multiple times, which leads to more surgical scarring. If radiation was part of the treatment, the scar tissue is due to both surgery and radiation. Massage may help to a certain degree. While I would continue stretching and massaging, one year out this may be your new baseline.

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Best ways to break up underarm scar tissue?

Question from Tzcps: What are the best ways to break up scar tissue under the arm after an axillary dissection and radiation?

Answer —Linda Miller, P.T.: Massage and stretching of the axilla is the best way to remodel scar tissue. I would suggest avoiding aggressive massage over previously radiated tissue because, as Dr. Brill has mentioned, the blood flow of radiated tissue is not as good as previous.

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Reconstruction possible with radiation scarring?

Question from Carole: I had breast cancer in 1989, followed by lumpectomy and radiation. Got it again last year, had double mastectomy and chemo. My doctor said I'm not a good candidate for reconstruction because of the hard scar tissue on the left side that was radiated in 1989. Is that true?

Answer —Kristin Brill, M.D., F.A.C.S.: Generally, radiation changes and blood supply to the tissue and skin improves over time so that, more than 2 or 3 years out from radiation, many plastic surgeons are comfortable offering some types of reconstruction. This can vary from woman to woman, as some women develop very dense scar tissue that make reconstruction more challenging, with a higher risk of complications. I would encourage you to actually see a plastic surgeon and talk about reconstruction options because the plastic surgeon would have the insight to know what sort of reconstruction may be available to you.

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Physical therapists trained in treating scar tissue?

Question from Sheree: How common is the knowledge about deep soft tissue work and scar tissue? I am having a difficult time finding therapists that are informed and/or comfortable working with mastectomy patients outside of MLD.

Answer —Linda Miller, P.T.: Unfortunately, this is a relatively new area for physical therapists to be treating on a regular basis, and for some therapists, an underlying cancer diagnosis can be intimidating to treat. More and more therapists are being trained in treating breast-cancer-related problems, and it's best to try to find one who specializes in the area.

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What causes chronic cellulitis?

Question from JoanneB: What causes chronic cellulitis?

Answers —Kristin Brill, M.D., F.A.C.S.: Chronic cellulitis can occur in the presence of lymphedema and exposure to infection.

Linda Miller, P.T.: Recurrent cellulitis with lymphedema can happen just spontaneously because lymphedema is a high-protein swelling and the protein acts as a breeding ground for normal bacteria to proliferate. So the nature of lymphedema fluids is to set up that breeding ground for bacteria, which is why the skin and arm care precautions are so important.

Kristin Brill, M.D., F.A.C.S.: One of the issues with chronic cellulitis is that the longer it goes on, the more challenging it is to treat. Initially, we start by treating with basic antibiotics to cover the most common bacteria and progress to stronger antibiotics at higher doses. For some women with true chronic lymphedema, there's some information about low-dose antibiotics to try to control or prevent worsening cellulitis.

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Lymphedema risk with physical activities?

Question from Momm: I had a lumpectomy and sentinel node surgery Dec. 2007 and then had 13 more lymph nodes removed Jan. 30, 2008. I normally go to the gym 2-3 times a week and use the resistance machines. I also golf 9 holes regularly in the spring and summer months. My main fear now is lymphedema. Is it safe to continue doing these activities?

Answer —Linda Miller, P.T.: The important thing to remember is that most women do not get lymphedema. There's some new research that suggests that women who exercise regularly do not increase their incidence of lymphedema. So the key is to keep your activity level constant: do not dramatically increase either the resistance or the amount of exercise you're doing. Gradually, if you want to increase to playing a full round of golf or lifting more weights, the key is going about that increase in activity gradually.

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How to massage scar tissue?

Question from Brenda Thostenson: I had a bilateral mastectomy in October without reconstruction. My scars are long and the skin is pulled very tight. My concern is scar tissue. How often and in what direction etc. should I rub or move my scars? They run from sternum to under the arm pits. No chemo or radiation needed from very low Oncotype score, but I am taking tamoxifen. Thank you, Brenda.

Answers —Kristin Brill, M.D., F.A.C.S.: Stretching and massaging along the scars can be helpful.

Linda Miller, P.T.: What we usually recommend is along the scar itself, you actually massage perpendicular to the scar line. Therapists call that transverse friction massage. But it's important not just to focus on the scar line itself. As Dr. Brill mentioned, that mastectomy procedure goes down into the trunk as well. So massage should be done on the skin above and below the incision.

Kristin Brill, M.D., F.A.C.S.: The distribution of the breast and where the surgery takes place extends from the collar bone down to the base of the ribcage and from the midline of the chest all the way to the midline side of the body. So this is all potential area for scar formation.

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Benefit to seeing physical therapist before surgery?

Question from Xaniella: Is there a benefit to seeing a physical therapist before having a mastectomy and lymph nodes removed?

Answer —Linda Miller, P.T.: I think a one-time consultation prior to surgery is an excellent idea. The therapist can take baseline measurements of both arms so that any post-operative changes can be detected. It's also a good time to get questions about lymphedema and return to activity answered. The therapist can also review some simple range of motion exercises that can be done once the drains are removed but before you actually get out to an outpatient therapist.

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Spot near incision discolored, sore, and hard?

Question from Annetta: I have a red/bluish circle next to my incision. Incision healed but this spot is painful, sore, and hard. One doc mentioned that it could be a seroma, but an ultrasound showed no fluid under the skin. Doc performed a skin biopsy today. Any thought on what this is?

Answer —Kristin Brill, M.D., F.A.C.S.: It can be a variety of things, including normal post-operative change or scarring secondary to radiation if that was done. If it doesn't appear to improve over time, a surgeon may do a punch biopsy to ensure that it's not related to the cancer.

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Shoulder pain from mastectomy with reconstruction?

Question from Nanc: Two weeks after a double mastectomy with implant reconstruction with the muscle lifted above the implant, I began having shoulder pain. I have been doing physical therapy now for about 6 months. While greatly improved, the shoulder still is a problem. How might the surgery relate to the problem and do you have any recommendations for remedies?

Answer —Kristin Brill, M.D., F.A.C.S.: That's a good question. Shoulder pain can come from many sources. It may be due to irritation of nerves that supply the shoulder joint and shoulder blade. It can be related to positioning during surgery or as part of recovery. It can be a primary shoulder joint or rotator cuff problem. If it persists, a shoulder MRI may be helpful to evaluate the cause.

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Cellulitis risk with sunbathing?

Question from Constance: I have lymphedema in my right arm after a mastectomy with 24 nodes removed. How do I deal with the sun and getting any type of tan? I'm terrified if I sit in the sun that I'll end up with cellulitis in my arm. Any suggestions?

Answer —Linda Miller, P.T.: The most important thing when you have lymphedema is to avoid any new trauma to the arm. That being said, with proper sun block to avoid a harsh burn, there's no reason why you can't go out into the sun. There's no evidence that getting a suntan causes lymphedema. The important thing is to avoid a burn.

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Fatigue long-term effect of surgery?

Question from BLoth: I had seven surgeries for breast cancer. I didn't have any infections or problems, but I still get very tired. Last surgery was 2/07 and last chemo was 12/05. Is tiredness is a long-term effect from the surgeries and treatments? I exercise regularly, eat a well-balanced diet, and take vitamins and supplements as directed by my nutritionist, who is an M.D.

Answers —Kristin Brill, M.D., F.A.C.S.: We shouldn't underestimate the degree of long-term effects of surgery. For many women, especially after multiple surgeries and chemotherapy, fatigue is an issue even years later. One important point would be to try to discern between treatment fatigue related to surgery, radiation, or chemotherapy, and lack of energy that may be more emotional or related to depression or more psychological issues. Sitting and talking with your medical oncologist may shed some light on the fatigue as well as evaluation using blood work and other tools or tests.

Linda Miller, P.T.: There's a lot of evidence that suggests that fatigue is the number one complaint of cancer patients. This fatigue can last for years following chemotherapy. The current research suggests that exercise, which is what you're doing now, is probably one of the best ways to combat cancer fatigue. As Dr. Brill said, blood levels are affected by chemotherapy and may take months to return to a close to normal baseline.

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Suggestions for treating keloids?

Question from Kathy: One year ago I had a mastectomy. I'm still experiencing many symptoms as discussed here, but wonder if you might have any suggestions for treating keloids?

Answer —Kristin Brill, M.D., F.A.C.S.: Keloid is bulky scar formation. A true keloid is a bulky, nodular scar that forms over months to years and can commonly form on the upper body, trunk, neck and back in those that tend to form keloids. Many women will consider hypotrophic scar (which is thickened scar) to be a keloid, when truly it is just a thicker than average scar. For women who know that they tend to form thicker scars, consultation with a plastic surgeon ahead of surgery can be helpful to modify techniques such as type of suture used, the possibility of injecting the scar with steroids post-operatively, or some topical agents to prevent scar thickening before it occurs. It's worth investigating these options for women who form hypertrophic scars or true keloids, as they can be the source of chronic pain and itch long-term.

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Side effects of TRAM flap reconstruction?

Question from Babzi: I have just had reconstruction. I was informed of complications that could happen to the breast but was not informed that I could have problems with my tummy where the tissue was taken from, which subsequently broke down and got infected. Should I have been informed about this before I had surgery?

Answer —Kristin Brill, M.D., F.A.C.S.: The type of reconstruction you're referring to is called a TRAM-flap where a part of the muscle, fatty tissue, and skin from the lower abdomen is rotated up to create breast reconstruction. While this is a beautiful reconstruction that typically does not require implants, some of the short-term and long-term issues can be abdominal wall weakness, hernia formation, risk of infection at the incision, and chronic pain, which is generally discussed as part of the scheduled side effects, or complications of this procedure.

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Weighing implant reconstruction risks?

Question from MargaretB: I had latissimus dorsi reconstruction almost 3 years ago and the implant has become encapsulated. My surgeon said that it will need to be replaced at some stage, but it's my decision when. I had a lot of complications after my original surgery -- skin necrosis, which took 2 years to heal. Should I have the surgery and risk problems again, just as life is getting back to normal?

Answer —Kristin Brill, M.D., F.A.C.S.: One issue with thick capsule or scar tissue formation around the implant is that it can create tightness across the chest and chronic pain or discomfort. Some of your decision may be based on your symptoms and how tolerable they are. Each woman is different, and while some form very little capsule around the implant, some form thick capsule that tends to form again even with revision or replacement of the implant. There are some techniques that may help minimize capsulation, including the type of implant selected, massage of the implant post-operatively, and stretching techniques.

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Biggest concerns, precautions with surgery?

Question from Messalina: If YOU were having breast surgery next week, what would be your biggest concern about post-surgery, and what precautions (if any) would you be taking to avoid problems?

Answers —Kristin Brill, M.D., F.A.C.S.: That's a good question.

Linda Miller, P.T.: Working as I do with breast cancer patients, I would share their concerns of developing lymphedema, even though as I said earlier most women do not get it. Probably the most important thing that I would do is to make sure that I get my shoulder motion back to normal as my comfort level dictates, and to get as active as I could as soon as I could.

Kristin Brill, M.D., F.A.C.S.: Embarking on a breast surgery requires that you have a good understanding of what's being done, not only with the surgeon but other members of your team, including the radiation oncologist, medical oncologist and physical therapist. Make sure that your questions are adequately answered and you have realistic expectations.

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Concerns about lymphedema and physical activities?

Question from WSD: I had 27 lymph nodes removed from my left underarm area and 13 removed from the right. My concern is lymphedema while trying to stay physically active and fit. What is your opinion about participating in dragon boat racing and using rebounders as part of an exercise regimen?

Answer —Linda Miller, P.T.: Dragon boating has become a popular way of exercising for breast cancer survivors. There have been a couple of papers published that have followed dragon boaters through their activity and have found no increase in the incidence of lymphedema or worsening of lymphedema in women who participate. That being said, the important thing if you're going to start this activity would be to make sure that your arms are ready to participate. This would include performing a good flexibility program and a light resistance program prior to excessive paddling. It is sometimes recommended that women who are at risk for lymphedema wear a well-fitted compression sleeve prior to starting such vigorous exercise; however, that is only a guideline and is not mandatory.

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Weight limit for carrying things after surgery?

Question from Rickey: You're told not to carry your purse, packages, etc. on your surgery side. How long can you not carry anything? Or is there a weight limit?

Answers —Kristin Brill, M.D., F.A.C.S.: Immediately post-operatively, one should take precautions to allow the incision to heal without incident and not disrupt any incision or drain. But longer-term, this should not be a restriction.

Linda Miller, P.T.: There's never been any research that looks at specific weight limits or weight restrictions. Often times these numbers have been picked randomly or from anecdotal reports. As I've stressed several times before in tonight's talk, there's no reason why women cannot go back and use their limb as normally and as functionally as needed. The key would be to return to any of these activities gradually. Long-term activity restriction is not supported in any lymphedema research.

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Normal for dye injection site to be hard?

Question from Blonde: I had a lumpectomy back in February and the area to the left of the incision is still hard where they injected the dye for a lymph node biopsy. Is this normal? The surgeon says it is but it really bugs me.

Answer —Kristin Brill, M.D., F.A.C.S.: There are different dyes that are used to map for sentinel nodes. The most common is isosulfan blue, which tends to stain or tattoo the skin but does not cause hardness. Some surgeons will use methylene blue, which has been known to create some reaction in the breast tissue called fat necrosis. This tends to resorb over time, but takes months or even years. Sometimes massage can help, and I would encourage you to talk to your surgeon about the cause of the hardness, whether it's related to injection or just simply scar tissue and what you can do to soften that up. Again, hardness at the lumpectomy site is common and expected soon after surgery and takes months to soften.

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Surgery drains affect lymphedema risk?

Question from Mimi: Do the drains used in surgery affect whether or not you may get lymphedema in your arm?

Answer —Kristin Brill, M.D., F.A.C.S.: No. Some mild swelling in the arm after breast and axillary surgery is normal and not considered lymphedema. The drains placed in the axilla after surgery are meant to collect the fluid that can accumulate and generally only remain in place for 1 to 2 weeks. This does not impact the risk of long-term lymphedema.

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Why do breast implants feel cold?

Question from Robbie: Why are my implants so cold?

Answer —Kristin Brill, M.D., F.A.C.S.: Implants placed after mastectomy tend to be a little cooler than the rest of the body, and a complaint or feature that women do appreciate over time, especially in women in colder climates. This is because the implants are filled with saline or silicone and essentially sit outside the chest cavity and just beneath the skin. They probably are, in fact, a degree or a few degrees cooler than the true body temperature.

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Permanent compression garment necessary?

Question from Artistry: I'm finishing chemo, about to have surgery. I have mild-moderate lymphedema as a result of sentinel biopsy. I've not started physical therapy, but at my consultation I was told I'd need to wear a garment on my arm for the rest of my life! Is this always the case? With treatment won't it ever improve to the point of not having to wear a special garment? Will mastectomy and radiation worsen it?

Answers —Linda Miller, P.T.: If you're experiencing lymphedema at/or around the time of chemotherapy, often times the edema is chemotherapy related and might be resulting from the use of steroids in the chemotherapy regiment. Often, after chemotherapy ends and with proper addressing of the edema at the time that it's occurring, much of the edema resolves. Often, many of these early onset edemas can be managed aggressively initially with exercise, manual lymph drainage and compression. However, many of these conditions do not warrant long-term daily use of compression garments. Radiation could worsen the edema temporarily during treatment, but again much of the worsening of the edema may resolve the further out you are from your radiation treatment. Edemas that occur during the time of treatment for breast cancer are often short-term conditions.

Kristin Brill, M.D., F.A.C.S.: If you are receiving chemotherapy prior to surgery and have had a sentinel node biopsy, some edema may be related to the initial procedure and just as Linda has said may be related to the fluid and electrolyte fluctuation we see with chemotherapy. This may indicate a more short-term edema issue and not necessarily long-term.

Linda Miller, P.T.: The important part here is that wearing a compression garment forever is not inevitable.

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Cramping pain normal in lumpectomy area?

Question from Clarice: I had a lumpectomy 5 years ago and am still experiencing pain in that area -- more like cramping that literally takes my breath away sometimes. My doctor’s standard reply has been the very false statement, "We're never concerned with pain in the breast because breast cancer isn't painful." Is this cramping-type pain normal or should I try to find another doctor?

Answer —Kristin Brill, M.D., F.A.C.S.: Again, pain at the lumpectomy site where scar tissue has formed from both surgery and radiation is very common, and in the vast majority of cases doesn't represent a problem outside of discomfort. Still, evaluation of that area is possible, not only with a good digital mammogram and physical exam but also ultrasound or breast MRI. While pain in the breast is not the most common symptom related to cancer, for someone who has significant pain, this may be an indication that denser scar tissue has formed and some limitations in screening may exist. So breast MRI may be a good adjunct to standard screening.

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Connection between surgery and stiffness/fibromyalgia?

Question from ThereseL: What is the connection between breast cancer surgery and chronic stiffness/fibromyalgia? I have been experiencing what I believe to be fibromyalgia since my surgery in '05 but never connected it to the surgery.

Answer —Kristin Brill, M.D., F.A.C.S.: I don't have scientific evidence, but I find that women who have been diagnosed with fibromyalgia tend to have more pain or post-op discomfort and even long-term pain following surgery. The source of this is probably related to some of the rheumatologic features of fibromyalgia. In addition, I believe women with fibromyalgia tend to have more bone pain and achiness with aromatase inhibitors.

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Soreness and lumpiness normal after lumpectomy?

Question from Baro: I had a lumpectomy January 2007, radiation in the spring, and now take Arimidex. I still have significant sore spots in that breast, though generally they only hurt if I touch them. Also the breast seems lumpy still. I had an MRI in March 08 and all is clear. Are the soreness and lumpiness normal?

Answers —Kristin Brill, M.D., F.A.C.S.: Yes, tenderness and lumpiness in the treated breast can be very normal. But you still require a good breast exam to monitor these changes and sufficient imaging to explain what you're feeling. Changes after any sort of breast cancer treatment are very common. Changes in light of a new diagnosis and treatment can be disconcerting to women. They need to understand what changes to anticipate and to have good communication with doctors and physical therapists to help explain what they're experiencing and what to expect, and how to modify some of their experiences. Mostly, to help reassure that what they're experiencing is normal and not the sign of a problem.

Linda Miller, P.T.: What I'd like to end with is that promising research has been done with women who have had breast cancer surgery and the importance of exercise and activity in preventing and managing lymphedema and other side effects of surgery. Stretching and resistance exercises can be a safe and effective part of any woman's post-operative long-term program.

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