We will start by looking at Bras, often for most women uncomfortable at the best of times and for me and many women the euphoria when you remove your bra is one of those little pleasures at the end of a long tiring day. Finding the right bra can be difficult and there is plenty of advice on how you should wear your bra as the image below shows.

What about bras for women who have had a mastectomy or breast-conserving surgery?

This article is about my experience of finding a bra after breast-conserving surgery and that took me four years after my operation. Why is that? When you have breast-conserving surgery, however tidy your scars are or not, when you have a lump or tissue removed the chances are that your breast is misshapen. There may be dents or the skin may be puckered and with Lymphoedema your breast is highly likely to be swollen. 

With the swelling your boob may swell at different times of the day. For example, your affected boob may start the day as a D cup, by lunch time you may be a double D cup and by teatime a triple D cup and your boob keeps swelling. Not everyone who has had post-operative surgery will experience this, but it does happen. Therefore, when you have one normal boob and one that swells throughout the day then finding a bra can be difficult.

You will need to find a bra that has wide enough sides so that you don’t spill out of them, seams should be soft, no harsh ridges. A bra with straps that do not cut into your shoulder and leave indentations (bra straps will be wider than you are used to). You may need to use cushion straps. Fastenings need to be easy to do up and undo and not leave marks. There needs to be good separation between the cups so that the middle lies flat and if the back of the bra rides up then it hasn’t been fitted correctly. Finally, no wires.

I learnt very quickly post-surgery that wearing matching lingerie/underwear was a thing of the past and not something manufacturers of post-operative bras where keen on. I did ask one of the manufacturers why this was. The general answer was that they had briefly tried this, and the company said it wasn’t cost-effective, to manufacture matching items, and they said in their experience there wasn’t a need.  This unfortunately means that whoever manufactures post-operative bras, as their customer, your choice is restricted. There is no, or very little decorative detail and colours are limited to beige, black or white.

However, a group of us where fortunate enough a few years ago to spend time at George Headquarters near Lutterworth and at the time they agreed with us and provided matching-coloured knickers for their coloured post-operative bras.

In our discussions with George, we stated that cotton linings where essential inside the cup as cotton is more absorbent and we asked for the lining to be made deeper.  Good post-operative bras will have a decent size pocket so that a prosthesis or massage pad will sit comfortably inside the pocket.

How do you find a post-operative bra that fits you properly and will make you feel comfortable and supported?

Ask your breast care clinic or Lymphoedema clinic whether they have access to a Bra Fitting service, this service will measure you properly and order the correct bra for you.

What happens when your clinic does not have this service? My advice is to look for a Lingerie Fitting Service and there are some good ones either on the High Street or within some Supermarkets.  Due to COVID, it is will highly likely that you will need to book an appointment to use a bra fitting service. When booking, ask for a Post-Surgery appointment.  You will find most of the manufacturers, and other fitting services have online appointments via video where they can talk through your requirements. Many of the retailers now have measurement charts on their websites so that you can measure yourself and then order. I would strongly advise you to see a fitter in person, less likelihood of the fitting going wrong.  

Swimwear

One of the best exercises/movements for Lymphoedema is swimming and post-surgery swimsuits need to be functional but there is more scope to find swimwear that is attractive as well as comfortable to wear. A wide variety of colourful fabrics are used, and you can accessorise swimwear with matching cover-ups, tunics, and kaftans.

Manufacturers are more conscious of design.  Swimwear needs to be able to cover scarring around the breast area and a higher neckline is needed.  The pocket openings need to hold a prosthesis securely and post-surgery swimsuits will often have softer outer cups providing a smoother look so that it is harder to tell the difference between a prosthesis or a natural breast.

Swimwear can have wider gusset, a lower leg, tummy control or even a little skirt if you are conscious of the top of your legs.  As with bras there are good fitting services available.

While the fitting service is free, the cost of post-operative bras is something you will probably have to pay for yourself.  Mastectomy bras are VAT exempt and there should be a box to tick on the order form for VAT exemption.

Macmillan Cancer Support provide one off grants for surgical, mastectomy bras and swimwear or other financial support associated with cancer.

NHS Financial Support may be available if you are on a low income or certain benefits.

Sue Hansard is a Lymphoedema Nurse Specialist at First Lymph Care

Sue has provided the following very helpful information:

FIRSTLY:

If you think you have developed Lymphoedema in the breast, chest wall, axilla..... don't panic.

Breast Lymphoedema, if assessed, diagnosed and treated promptly can resolve completely and can be reduced to self management levels similarly to limb Lymphoedema .

WHAT IS IT?

Put simply: swelling in the breast tissue, or the chest wall which occurs after trauma or infection or following treatment for breast cancer. It occurs more frequently following removal of lymph nodes and /or radiotherapy or less commonly after chemotherapy.

WHAT DOES IT LOOK LIKE?

The affected area is the operated side of the chest, including breast, chest,

armpit and the upper back on the operated side.

Any of these areas may be visibly swollen, may feel soft, or firm and feel tender/sore. The skin may be pink/red and may appear tight or dimpled like orange peel. There may be a dull ache or sharp pain, pins and needles, tingling or numbness all due to damaged nerves and the pressure of fluid within the tissues which aggravate the nerve endings.

It is vital that you are assessed by a Lymphoedema specialist who can advise , treat and teach you appropriately.

Your Lymphoedema therapist. will ultimately be aiming to reduce your swelling , reduce your pain, improve skin and show you how to confidently self- manage it in the longer term.
 

MY TOP 10 TIPS FOR SELF MANAGEMENT

With thanks to Cancer Research UK

Background Information

Mrs B, a 68 year old woman had been diagnosed with Grade 2, oestrogen receptor positive left breast cancer at a routine mammogram in 2016. She underwent Wide Local Excision (WLE) and Axillary Node Clearance (ANC). Thirteen Lymph nodes were removed and two were positive for cancer.

Following surgery and after wound healing, she underwent fifteen fractions of radiotherapy to the chest wall and affected quadrant. She is now being treated with Letrozole (hormone therapy drug) and reviewed by her oncologist at six monthly intervals.

Post operatively, Mrs. B developed seromas (pockets of fluid that build up under the surface of the skin) in the affected breast. These were drained seven times by needle aspiration. Following radiotherapy, she developed a cellulitis infection in the breast and had a two-week course of antibiotics.

Patient Referral

At this stage, Mrs. B’s Breast Care nurse referred her to the Mary Ann Evans Hospice Lymphoedema Service where assessment took place within two weeks.

Physical Examination

On examination, the affected left breast was pink and warm to the touch. She did not have systemic symptoms of infection. The breast skin was dimpled, with `peau d’orange’ appearance. The subcutis was firm to the lower quadrants and she experienced moderate to severe transient breast pain. The breast shape was distorted and presented as early stage radiotherapy induced morphea. This rare but disfiguring side effect of radiotherapy is very difficult to treat. Over time tissues can become hardened, retracted, more discoloured and increasingly painful.

Soft oedema was palpable to the posterior axilla, sub-scapular area. Limb volume measurements were taken and showed a 3.4% difference between affected left and non-affected R dominant arm. There was no palpable oedema to the limb.

Mrs. B is a non-smoker; she had a BMI of 30 but was fairly active. She was keen to resume swimming and a supervised gym routine using resistance machines. She was quite low in mood due to the pain and embarrassed by the appearance of her breast. She wore looser fit tops to disguise the breast shape.

Initial treatment plan

1. Advice was given on skin care1
2. Self Lymphatic Drainage Massage and shoulder mobilization exercises were taught, with instruction to carry out twice daily.2
3. MLD weekly, in clinic. (NB: distance meant it was not feasible to carry out more than one MLD treatment a week)3
4. Kinesiology Taping - providing there was no sensitivity on patch testing4
5. Use of a supportive ‘sports bra’5
6. 6 Use of ‘Foam’ breast pads, made by clinical team
7. Mrs B. had eight weekly MLD sessions, during which breast tissue began to soften slightly. Low Level Infrared Light Therapy (LLLT) was introduced: 12 fortnightly sessions were carried out

LLLT treatment protocol

Duration: 10 minutes Frequency: 2.5 Hz

Directed on lower quadrants and supraclavicular region after emptying of lymph nodes. Taping was discontinued initially, MLD continued after LLLT treatments sessions had stopped.

Initial Outcome

Gradually breast pain began to improve but did not fully resolve. Skin improved, becoming more supple and pliant. Lower quadrants improved during treatment but became firmer again as days between appointments passed. Mrs. B was by now attending a gym three times a week using gentle resistance machines and swimming once a week. Unfortunately Mrs B. developed cellulitis again, which caused the breast to become firm and tender. This was treated with a 2-week course of antibiotics.

In October 2017, the clinic trialled the Hivamat 200 Deep Oscillation Therapy (DOT) and Mrs B was keen to try this; she had five treatments in total at fortnightly intervals.

Practitioner applying deep oscillation to breast via vinyl gloves, which transmit intermittent electrostatic impulses to the tissue, creating a resonant vibration in the tissue layers reducing swelling, fibrosis and pain

Frequency: 200 Hz Mode: 5

Duration: 20 minutes

During treatment, the therapist worked over the right axillary lymph nodes to encourage emptying and then worked directionally, encouraging superficial lymph flow towards the right axilla and away from the swollen areas and into deeper drainage pathways. We worked anteriorly and posteriorly.

While working with MLD, the therapist can feel subtle changes in tissue tone. When using DOT. therapists noted that these changes occurred more quickly and with even lighter pressures than MLD alone. Half way through this course, Mrs B sustained a soft tissue injury to the breast making it very painful to touch. However, with DOT we were able to treat without causing any discomfort, and by the 4th DOT treatment the affected breast was visibly softer. Even deeper tissues were softening and the breast was regaining a more natural shape. 

Patient Feedback

Mrs. B is delighted with the results. Her breast pain has resolved and she can now wear close fitting clothes without worrying about her shape. She is now confident and walks more upright. She is brighter in mood and beginning to enjoy life again. She writes, “The PhysioPod Deep Oscillation is brilliant. My symptoms have improved. My breast is now soft and I have no pain or soreness. I was sceptical at first, but it worked first time. So keep up the good work and thank you again.”

Therapist Conclusion:

“I have worked in Lymphoedema management for twenty years and have treated many patients with breast lymphoedema, caused the breast to become firm and tender. including several with radiotherapy induced morphea. DOT achieved deeper tissue changes which MLD and combined treatments had not and it achieved the changes faster and more gently than MLD alone. In 2009, I attended a presentation of the following study at The BLS Conference in Belfast and was pleased to witness that these findings echoed those of the following study:


“Effect of treatment with low-intensity and extremely low- frequency electrostatic fields (deep oscillation®) on breast tissue and pain in patients with secondary breast lymphoedema “

by Silke Jahr, Birgit Schoppe and Anett Reisshauer From the Department of Physical Medicine and Rehabilitation, Charité-Universitetsmedizin Berlin, Germany. J Rehabil Med 2008; 40: 645–650 

 

Secondary Lymphoedema of the Breast

“The lady, aged 46, came to me after breast cancer treatment, which included lumpectomy, lymph node dissection, chemotherapy and radiotherapy. She developed Lymphoedema of her right breast soon after radiotherapy and was in a lot of pain, also due to scar tissue and cording. After the first treatment with MLD and DEEP OSCILLATION® Naomi found relief from the pain and discomfort and her breast no longer felt hard and heavy. She found the treatment itself very relaxing and soothing. Naomi's oedema is now managed with regular MLD with DEEP OSCILLATION®, compression, skin care and exercises.”

Regina Dengler, RGN, BLS, MLD UK, Casley-Smith, MLD DLT Practitioner and Lymphoedema Therapist

PhysioPod 'A fantastic breakthrough for lymphoedema patients to manage the MLD themselves with this aid"

"It has been a journey trying to find answers of how to manage oedema of my left breast after radiotherapy.

The do's and don'ts of lessening the chances of this happening and finding people to help, for reassurance and guidance if anything,  has been enigmatic.

The NHS breast nurses had been amazing, however discussions about lymphoedema just lead to a booklet and pamphlets. Waiting time to see a Lymphoedema Specialist was months in the future. I looked them out privately and wished I'd been advised to do this soon as possible after radiotherapy.

I finally came across a brilliant specialist in Norwich who uses Hivamat/Physiopod on all her patients with excellent results. It was through her I have my own individual Physiopod. I can take it abroad. I have not taken it on long haul flights yet, but it is hugely reassuring that I can.

The Physiopod is a fantastic breakthrough for lymphoedema patients to manage the MLD themselves with this aid. While it is expensive you will have it wherever you are and when you need it for relief from the hardness and discomfort that can build up with oedema/lymphoedema and keep it managed. This reassurance gives you control.

So anyone reading this please act sooner and take matters into your own hands. If you can buy or find a specialist that uses this wonderful technology don't delay.

PhysioPod are an excellent, very friendly and understanding support team.

Yours very sincerely

Victoria" 

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