Exercise after Breast Reconstruction Surgery: Evaluating Current Trends and Practices of U.S. Plastic Surgeons

Breast reconstruction surgery after mastectomy has been associated with both psychosocial and aesthetic benefits in breast cancer patients.1 However, patients have reported restricted mobility, pain, lymphedema, and impaired sensation and strength after breast reconstruction surgery.2 Although plastic surgeons aim to balance technical, aesthetic, and functional outcomes, some functional deficits are inevitable, especially in the early postoperative period. The degree of functional deficit experienced by patients is dependent on both the type of reconstruction and the patient’s baseline functionality. Although it is true that some functional deficits are to be expected, there is evidence that they can be mitigated by optimizing postsurgical function using exercise and physical therapy. Exercise has been shown to lead to statistically significant improvements in quality of life in breast cancer patients,3 and has been associated with lower all–cause and breast cancer–specific mortality.4 In 2010, McNeely et al found that early structured exercise intervention after oncologic breast surgery leads to significant improvement in shoulder range of motion.5 Introduction of upper extremity exercise as early as postoperative day 1 after axillary lymph node dissection showed clear short-term benefit over delayed exercise (day 5–7 postoperatively) for shoulder range of motion. There was a statistically significant increase in wound drainage that required drains to stay in place approximately one additional day longer than if exercise was delayed by 1 week; however, there was no statistically significant difference in wound healing, seroma formation, pain, or wound aspirations between early and delayed exercise. The authors also found no evidence of a negative effect from upper extremity exercise on the incidence of upper limb lymphedema at any time point following surgery.5 With regard to breast reconstruction surgery specifically from a surgeon’s standpoint, there is an understandable concern that exercise can potentially lead to postoperative complications or even reconstruction failure. However, breast reconstruction surgery can lead to functional deficits that may largely impact the patient’s quality of life.6–9 Mizgala et al investigated abdominal strength after transverse rectus abdominis myocutaneous (TRAM) flap surgery.10 The authors found that 46% of women 5–7 years postoperative reported decreased abdominal strength and 25% noted a decrease in the ability to perform exercise, but activities of daily living were rarely affected (4%–5.8%). Sit-up performance was worse in postoperative patients when compared with unoperated controls (P < 0.0005).10 Unfortunately, literature pertaining to exercise after breast reconstruction surgery is limited. A study in 2013 by de Oliveira et al investigated the functional effects of immediate breast reconstruction with latissimus dorsi flap and concluded that there were no detrimental effects on shoulder motion.11 It is important to note, however, that all patients in this study were started on physical therapy three times a week for 4 weeks, starting the first day postoperatively. Breast centers around the country have begun to incorporate physical therapy (PT) and exercise into their standard recovery program. For example, McAnaw et al describe a comprehensive PT program for their patients who undergo breast reconstruction surgery at the University of North Carolina-Chapel Hill.12 Patients begin PT on the first postoperative day and continue therapy with gentle stretches and relaxation techniques while the drains are in place. Patients then progress to more involved PT with longer stretches and greater range of motion once drains are removed. The authors suggest an automatic referral to PT following breast reconstruction surgery. Physical therapists discuss preferences with surgeons and develop a working protocol for each type of procedure, encouraging them to alert the physical therapist about any special precautions for patients.12 In the United Kingdom, the usual National Health System postoperative care pathway for breast reconstruction includes routine postoperative physiotherapy that begins during the first postoperative week. In the British Association of Plastic Reconstructive and Aesthetic Surgeons Guidelines for Best Practice in Oncoplastic Breast Surgery, they state that all patients should have early access to specialist physiotherapy after oncoplastic breast reconstruction surgery. Physiotherapists must be familiar with the surgical techniques and potential surgical complications, so that they may work with patients as early as possible to regain full function of the arm and simultaneously reduce morbidity.13 At this time, there are no established guidelines for postoperative exercise and rehabilitation after breast reconstruction surgery in the United States, and there is a paucity of literature to support decision-making regarding this topic. The purpose of this study was to evaluate current trends and practices related to patient exercise after breast reconstruction among plastic surgeons in the United States.