Mastectomy scar
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A mastectomy scar develops as a result of the surgical removal of the entire breast, sometimes along with the nipple-areola complex, a portion of the skin, and axillary lymph nodes. Its appearance and course depend on the extent of the surgery, the reconstruction technique used, tissue tension, individual tendency to scar, and adjuvant therapy, especially radiotherapy. The scar is not solely an aesthetic change. It can cause pain, itching, hypersensitivity, a pulling sensation, reduced shoulder mobility, or adhesions between the skin, fascia, and chest wall muscles. Proper care includes monitoring wound healing, prevention of hypertrophic scarring, physiotherapy, and, upon completion of oncological treatment and obtaining a doctor's approval, appropriately selected scar remodeling methods.
Mastectomy scar - what does it look like
The appearance of the scar depends primarily on the type of mastectomy and the method of defect closure. After a simple mastectomy, a transverse or slightly oblique scar running across the anterior surface of the chest most commonly remains. After skin-sparing or nipple-areola complex-sparing surgery, the incision line may be located around the areola, in the inframammary fold, or in the lateral part of the breast. Tissue flap reconstruction may leave an additional scar at the donor site, for example on the abdomen, back, or thigh.
In the normal course, the scar:
- initially is pink or red, slightly raised, and firmer;
- gradually fades, softens, and flattens over the following months;
- may cause itching, numbness, tingling, or hypersensitivity for some time;
- ultimately usually becomes lighter than the surrounding skin, although in individuals with a darker phototype it may remain hyperpigmented.
After the transection of small cutaneous nerves, permanent or partially reversible sensory impairment may occur. Burning, stabbing, or electric-shock-like pain may indicate neuropathic pain or the formation of a neuroma, which is hyperreactive tissue at the site of nerve injury.
Abnormal scar types include:
- hypertrophic scar, raised, red, and remaining within the boundaries of the original incision;
- keloid, extending beyond the boundaries of the wound;
- atrophic or widened scar, thin and depressed;
- adherent scar, poorly mobile relative to deeper tissues;
- contracture scar, limiting the mobility of the skin, chest, or upper limb.
Radiotherapy can cause fibrosis, microcirculatory disturbances, skin thinning or hardening, and telangiectasias. These changes should not be automatically treated as ordinary "aging" of the scar. A new lump, a non-healing ulceration, bleeding, increasing induration, or a change in the appearance of a long-stabilized scar requires oncological follow-up to rule out local recurrence.
Mastectomy scar - how long does it take to heal
Healing occurs in stages, and the boundaries between individual phases are fluid:
- Inflammatory phase, usually the first 3-5 days. Hemostasis, the influx of inflammatory cells, and the removal of damaged tissues occur. Swelling, moderate tenderness, and pinkish discoloration of the wound edges can be physiological.
- Proliferative phase, from a few days to about 3-6 weeks. Fibroblasts produce extracellular matrix and type III collagen, new vessels develop, and the wound regains epidermal continuity. A surgical wound often closes within 2-4 weeks, but this does not mean it has regained full strength.
- Remodeling phase, starting after several weeks and usually lasting 12-18 months, sometimes up to 24 months. Type III collagen is gradually replaced by type I collagen, fibers change their orientation, and the scar fades and softens. Even a mature scar does not regain all the mechanical properties of intact skin.
The rate of healing can be slowed down by:
- radiotherapy or chemotherapy;
- infection, wound dehiscence, hematoma, or seroma;
- reconstruction using an implant or tissue flap;
- tobacco smoking, diabetes, anemia, and malnutrition;
- obesity, significant wound edge tension, and impaired blood supply to skin flaps;
- the use of certain medications, including glucocorticosteroids;
- lymphedema and recurrent skin inflammation.
Urgent consultation is required for: increasing redness, an increase in local temperature, purulent discharge, foul odor, fever, wound dehiscence, rapidly expanding swelling, or sudden bruising. The same applies to implant exposure or persistent fluid leakage.
Mastectomy scar - when can its therapy begin
The timing of starting therapy depends on the type of procedure. Massage, needling, and energy-based treatments must not be performed on an open, oozing, or infected wound. Oncological treatment and the safety of the reconstruction always take precedence.
An indicative timeline includes:
- immediately after surgery: wound protection according to the surgeon's recommendations, proper nutrition, smoking cessation, and gentle breathing and movement exercises recommended by a physiotherapist;
- after full wound closure and removal of sutures or drains: silicone gel or silicone sheets may be considered upon the surgeon's approval; the product is not to be used on an unhealed wound;
- usually after about 4-6 weeks: careful mobilization of the scar and adjacent tissues is possible if there are no complications;
- after healing stabilizes and upon agreement with the surgeon and oncologist: the patient may be qualified for dermatological or aesthetic medicine procedures.
The basis of conservative management consists of silicone, UV protection, and gradual physiotherapy. Silicone increases hydration of the stratum corneum and can reduce fibroblast activity. Its use is best documented in the prevention and treatment of hypertrophic scars, although the quality of evidence is not uniform. Massage and mobilization can improve tissue glide and reduce the pulling sensation, but they should not be painful or cause persistent redness.
In the event of pain, restricted shoulder mobility, adhesions, or swelling, oncological physiotherapy is indicated. It should include an assessment of shoulder girdle mobility, tissue glide, chest function, and the risk of lymphedema. Swelling of the limb on the operated side should not be intensively massaged without a prior diagnosis and the development of a specialized therapy plan.
Ambasada Urody offers the following procedures intended for the remodeling of postoperative scars, which may also be considered in the case of a post-mastectomy scar:
- fractional CO₂ laser and ablative Er:YAG/iPixel laser, used to remodel thickened, uneven, or contractured tissue;
- 1540 nm non-ablative fractional laser, acting in the dermis while preserving the continuity of the epidermis;
- Alma Hybrid/OScar hybrid laser, combining CO₂ ablative and 1540 nm non-ablative action;
- ClearLift Q-Switch, offered as a gentler non-ablative method;
- 3D DeAge EX microneedle radiofrequency, utilizing microneedling and controlled heating of the dermis;
- Pixel RF microplasma, acting fractionally on the epidermis and deeper layers;
- autologous therapies: platelet-rich plasma, fibrin, plasma concentrate, and CGF;
- carboxytherapy, collagen mesotherapy, LED therapy, and oxygen infusion, treated as supportive procedures.
Fractional laser therapy can improve the thickness, elasticity, texture, and symptoms of a scar, but it does not remove it completely. In the case of a post-mastectomy scar, parameters must take into account radiation therapy, the thickness of tissues over the implant, sensory disturbances, and the status of the reconstruction. Evidence for some of the supportive procedures, especially mesotherapy, carboxytherapy, oxygen infusion, and autologous preparations, is weaker than for silicone and selected laser methods. They should not replace surgical follow-up, hypertrophic scar treatment, or oncological rehabilitation.
