Postoperative Rehabilitation Guidelines After Bilateral Mastectomy with Tissue Expanders
Early rehabilitation intervention is essential following bilateral mastectomy with tissue expanders to optimize functional outcomes, prevent complications, and improve quality of life.
Immediate Postoperative Phase (0-3 days)
- Begin rehabilitation immediately in the postoperative period to prevent complications and improve outcomes 1
- Initial exercises should focus on:
- Gentle shoulder range of motion exercises within pain tolerance
- Deep breathing exercises to prevent pulmonary complications
- Early ambulation to prevent venous thromboembolism
- Pain management is critical during this phase:
- Consider botulinum toxin infiltration of chest wall musculature to reduce pain and muscle spasm 2
- Adequate analgesia to allow participation in early rehabilitation activities
Early Recovery Phase (4-14 days)
- Progress shoulder range of motion exercises gradually:
- Forward flexion, abduction, and external rotation within pain limits
- Avoid aggressive stretching that could compromise surgical site
- Monitor for signs of wound healing complications, especially in patients with risk factors:
- Smoking and obesity increase risk of complications for all types of breast reconstruction 3
- Begin functional activities as tolerated:
- Personal hygiene activities
- Light household activities below shoulder level
Intermediate Phase (2-6 weeks)
- Continue progressive shoulder mobilization:
- Aim to restore full range of motion by 6 weeks
- Add gentle strengthening exercises as tolerated
- Tissue expansion typically begins during this phase:
- Coordinate rehabilitation with expansion schedule
- Expansion may cause temporary increased discomfort requiring adjustment of exercise program 4
- Monitor for complications:
- Capsular contracture
- Malposition of expanders
- Poor cosmetic outcomes 3
Advanced Phase (6+ weeks)
- Progress to full functional activities and strengthening:
- Gradual return to all activities including overhead movements
- Incorporate exercises to address postural changes
- Continue coordination with expansion schedule:
- Adjust exercises based on discomfort after expansion sessions 4
- Address psychosocial aspects of recovery:
- Consider group-based rehabilitation programs to address emotional aspects of recovery 5
Special Considerations
Radiation Therapy
- When postmastectomy radiation is required with implant reconstruction:
- Immediate rather than delayed reconstruction is preferred to avoid tissue expansion of radiated skin flaps 3
- Tissue expansion of irradiated skin increases risk of capsular contracture (>30%), malposition, poor cosmesis, and implant exposure 3
- Surgery to exchange tissue expanders with permanent implants can be performed before radiation or after completion of radiation therapy 3
Timing of Reconstruction
- The timing and technique of reconstructive procedures should be discussed preoperatively on an individual basis by all specialists involved 3
- Postmastectomy radiation is not a standalone reason to postpone reconstruction 3
Monitoring and Follow-up
- Regular assessment of:
- Shoulder range of motion
- Upper extremity circumference (to detect lymphedema)
- Functional activities
- Pain levels
- Patients not satisfied with cosmetic outcomes after completion of treatment should be offered plastic surgery consultation 3
Cautions and Contraindications
- Avoid aggressive stretching in the immediate postoperative period
- Modify exercise program based on:
- Wound healing status
- Pain levels
- Tissue expansion schedule
- Smoking is a relative contraindication to breast reconstruction due to increased risk of wound healing complications 3
Early rehabilitation programs have been shown to significantly improve range of shoulder motion and functional outcomes without increasing postoperative complications compared to standard care 1.