Rebuilding After Breast Cancer
Since Eve Gentry’s radical mastectomy in the 1950s Pilates and breast cancer have had a near-legendary relationship. Breast cancer treatment and rehabilitation has come a long way since then, and Pilates remains an effective movement modality throughout treatment and survivorship. As Pilates instructors, knowing how to work with the primary types of post-mastectomy reconstruction can facilitate a “return to life” for our clients.
There are three main categories of post-mastectomy reconstruction: prosthesis reconstruction, autologous tissue reconstruction, and aesthetic flat closure. In this article, we’ll share how Pilates instructors can better support clients after a mastectomy by understanding the specific guidelines for each type of surgery.
So what is Prosthesis Reconstruction?
Breast prosthesis (or implant) is the most common post-mastectomy reconstruction. Breast implants are made from silicone and filled with silicone or saline. They generally require two surgeries: a tissue expander, then an implant placed several weeks later.
After the first surgery, the tissue expander is filled with saline to stretch the tissue around the implant. As the tissue expands it stretches the pectoral muscles, pulling on structural elements like the clavicles, and creating tightness in the upper back.
During this time, clients will have weight-bearing restrictions. Pre-Pilates and matwork are safe and effective, although Swan Dive and Seal should be avoided. On the reformer, instructors should avoid arm and chest-focused exercises that require pushing or pulling springs (Pull Straps, Chest Expansion, Rowing, Long Stretch, etc.). On the Cadillac, Push-Through also puts too much demand on the tissue.
After tissue expansion, an implant will be placed under (subpectoral prosthesis placement) or over (prepectoral prosthesis placement) the pectoralis. Understanding this placement can help instructors make optimal programming choices.
Subpectoral prosthesis placement is more common and also more complicated. Challenges can include upper body weakness and “animation deformity,” when the implants “jump” when the chest muscles contract.
After the tissue expander is removed and a subpectoral implant placed, the client will be ready to rebuild strength. Clients may need to continue with the protocol from the tissue expansion phase, building strength to work back to the repertoire.
When implants are placed over the pectoral muscle, the client avoids many of the weight-bearing restrictions of subpectoral placement. This approach to reconstruction uses a biologic mesh instead of muscle to hold the implant in place, reducing side effects. Once clients are cleared for exercise, they can often pick up where they left off pre-surgery with few restrictions, although full push ups are generally contraindicated for both types of implant.
What is Autologous Tissue Reconstruction?
A more complex surgery than prosthesis placement is autologous tissue reconstruction which uses the client’s own abdominal tissue for reconstruction. These are long and complex surgeries with two surgical sites to heal, but with the benefit of using the patient’s own tissue, rather than a foreign object, for reconstruction.
The two types of Autologous Tissue Reconstruction are DIEP flap and TRAM flap. DIEP flap is a complex vascular surgery, in which some nerves to the rectus abdominus are severed. Clients will initially require postnatal, diastasis recti protocol, as they may not be able to access or engage abdominal muscles. Abdominal cramping is also common in c-curve exercises.
TRAM flap cuts the rectus abdominus and uses that muscle to reconstruct the breast, making it difficult to recover abdominal strength. When we work on oblique and transverse abdominal strength we can help clients reclaim some of the stability lost in rectus disruption. Progress with TRAM flap may be significantly slower than DIEP flap, and instructors should use care to protect the lower back.
What is Aesthetic Flat Closure?
Aesthetic Flat Closure (AFC) at the time of mastectomy has the benefit of leaving the client virtually unrestricted once healed and cleared to exercise. The client can quickly reclaim their pre-surgical Pilates practice. AFC may also be performed after explant– or implant removal– surgery. This usually requires the stretched pectoral muscles to be reattached to the chest with dissolvable stitches so that the muscles can contract to their original shape.
Sometimes the surgeon does not achieve a flat appearance on the first try, and the client may have loose skin that can become irritated. While Pilates cannot address this specific issue, it is important to be compassionate about this very real discomfort during exercise.
Special Considerations
Its important to note that mastectomies and reconstructions are not always done bilaterally. Sometimes clients opt to remove only the breast with cancer, so the reconstruction is done on one side only. In this case, instructors should consider working in a 2:1 ratio on the affected side.
With any reconstruction, it’s critical to watch client progress over time. Scar tissue can continue to build around the site, causing tightness and even misalignment of the clavicle and shoulder girdle.
Understanding how to work with each type of reconstruction– and how to talk about reconstruction with clients– ensures better outcomes and can also build trust in both the Pilates method and our studios, continuing the legacy of Pilates for breast cancer rehabilitation.
Melissa Miles is the owner of Melissa Miles Wellness, a lead trainer for Real Pilates NYC, and founder and President of the BOD of Teasers For Tatas, a 501(c)3 that fundraises through Pilates for the breast cancer community. As a breast cancer survivor, she is committed to educating Pilates instructors worldwide about how to work with those affected by breast cancer before, during and after treatment.
Kristen Davis co-owns The St Louis Pilates Lab, a host training studio for Real Pilates NYC, and has extensively studied the work of Eve Gentry, Kathy Grant, and Romana Kryzanowska. She presents workshops on working with special populations and serves as Vice President of the BOD of Teasers For Tatas.
For more information on fundraising or education events, visit www.teasersfortatas.org or email info@teasersfortatas.org