Why does my reconstruction still hurt?

Persistent pain after breast reconstruction is common. Much of the time it has identifiable causes, and those causes differ enormously in how treatable they are.

If your breast reconstruction still hurts, you are not an outlier, and you are not being ungrateful. A meta-analysis of 187 studies covering 297,612 patients found that 35% reported pain persisting three months or longer after breast cancer surgery, rising to 46% when patients were asked directly rather than when a clinician recorded it. That figure covers breast cancer surgery broadly, rather than reconstruction specifically. A separate meta-analysis found no significant increase in persistent pain among patients who underwent reconstruction compared with those who had mastectomy alone.

This is common, and it is reported far more often by the people living with it than by the people treating it. The important question is what is causing your pain, and whether something can be done about it.

Where the pain comes from

Pain after breast reconstruction can come from the mastectomy, lymph node surgery, radiation, the reconstruction itself, or a combination of these, and it usually traces back to what happened to the tissue rather than to the reconstruction alone.

A mastectomy cuts the sensory nerves supplying the breast skin and the breast tissue itself. The injured end of a cut nerve can form a neuroma, a sensitive growth of nerve tissue that hurts on its own. Surgery can also disrupt the thin covering of the chest muscle, called fascia, and leave scar tissue that restricts movement or tethers the skin to the muscle. It is frequently accompanied by surgery in the axilla, which can irritate nerves, produce neuromas of its own, and remove the fat pad that keeps the skin from adhering to the chest wall. Several of these problems may occur together.

Radiation exacerbates all of it and adds fibrosis of the skin, the subcutaneous tissue, and the muscle.

Implants introduce another potential source of discomfort. The body forms a scar tissue capsule around every implant. That capsule is usually soft and painless, but tightening or thickening can cause discomfort, sometimes before there is obvious distortion of the breast. An implant beneath the pectoralis muscle can also cause discomfort when the muscle contracts and moves the implant, a phenomenon called animation deformity.

Reconstruction using your own tissue, called autologous reconstruction, avoids an implant capsule and introduces healthy tissue into the treated area, which can be particularly helpful in those who have had radiation therapy. Even so, comparisons between reconstruction types have never shown one technique to be reliably less painful than another, largely because the patients who most need autologous tissue are often the ones who were irradiated, and irradiation is among the strongest predictors of long-term pain.

Some of these respond well to treatment

Identifying the likely sources of pain after breast reconstruction helps determine which treatments have a reasonable chance of helping. That requires a detailed history and examination, sometimes supplemented by imaging or a targeted nerve block.

Stiffness after a period of reduced movement often improves with physical therapy, range of motion exercises, and appropriate pain management. Progress takes time, but meaningful gains are possible.

Pain related to an implant capsule sometimes improves without an operation. Persistent or worsening symptoms may warrant surgery to release or remove the capsule, move the implant from beneath the chest muscle to above it, or remove the implant and convert to autologous reconstruction. In our experience, the last of those produces the most substantial improvement in patients with implant-associated tightness or pain from animation.

Neuromas can be difficult to pinpoint. When an injured nerve can be identified as a source of pain, both nonsurgical and surgical treatments may be available. Not all nerve pain comes from a discrete neuroma, however, and some patients benefit from specialist pain management.

When several causes coexist, treating one may improve symptoms without resolving them completely.

Radiation changes are harder to treat

Radiation fibrosis after breast reconstruction can be particularly difficult to improve. Some symptoms ease with time and rehabilitation, but established fibrosis should not be expected to disappear on its own. For selected patients, adding healthy autologous tissue beneath irradiated skin and over the chest muscle can improve comfort and tissue quality, and we will often release the scarred muscle during that reconstruction. These efforts need to be combined with range of motion work, physical therapy, and massage. All of that helps, although none of it can completely reverse the effects of radiation therapy.

Common and acceptable are different claims

Persistent pain after breast reconstruction is unfortunately common. That does not mean it should be dismissed as something you simply have to live with. A careful assessment can help distinguish symptoms likely to respond to rehabilitation, pain treatment, or revision surgery. Sometimes the cause remains uncertain, and improvement is less predictable. That uncertainty deserves an honest discussion.

We have written elsewhere about who decides whether a reconstruction worked. Comfort belongs in that assessment, alongside appearance. A reconstruction can look successful and still leave a patient with symptoms worth addressing.

References

Wang L, Cohen JC, Devasenapathy N, et al. Prevalence and intensity of persistent post-surgical pain following breast cancer surgery: a systematic review and meta-analysis of observational studies. British Journal of Anaesthesia. 2020;125(3):346–357. doi:10.1016/j.bja.2020.04.088

Reghunathan M, Rahgozar P, Sbitany H, Srinivasa DR. Breast reconstruction does not increase the incidence of postmastectomy pain syndrome: results of a meta-analysis. Annals of Plastic Surgery. 2020;84(5):611–617. doi:10.1097/SAP.0000000000002062

Chang PJ, Asher A, Smith SR. A targeted approach to post-mastectomy pain and persistent pain following breast cancer treatment. Cancers. 2021;13(20):5191. doi:10.3390/cancers13205191

Coriddi M, Shenaq D, Kenworthy E, et al. Autologous breast reconstruction after failed implant-based reconstruction: evaluation of surgical and patient-reported outcomes and quality of life. Plastic and Reconstructive Surgery. 2019;143(2):373–379. doi:10.1097/PRS.0000000000005197

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