Dermatologist Dr Justine Hextall explores the types of scarring related to breast cancer treatment, the impact they can have on patients and how healthcare professionals can support patients to care for them.
Types of scars occurring in breast cancer patients
From investigative procedures to surgical treatments, breast cancer patients are prone to developing scars at various stages of their cancer journey. The below advice explains the different types of scars they might have been left with and what they can expect them to look like, which can help to better prepare them psychologically.
The type of scar after a mastectomy will depend upon the surgical procedure undertaken. For example a mastectomy may remove the breast tissue but spare the skin and nipple. In others the skin and muscle may be removed and as such a more complicated repair is required and recovery time will be longer. The mastectomy scar shape and appearance will depend on the type of mastectomy undertaken. Most surgeons perform simple mastectomies by an elliptical incision (in the shape similar to that of an eye) that leaves a single scar across the chest. Elliptical incisions are designed so that the resulting scar runs parallel with existing skin creases. This usually provides a wound under less tension and orientates the scar in a direction that is less noticeable to the eye.
Breast reconstruction scars
Around 56% of women will opt to have a breast reconstruction following a mastectomy. If the original breast skin can be saved, scars can be concealed in the inframammary fold, or around the areola, which is often tattooed to hide small scars. In cases where all of the breast is removed, a flap reconstruction is common (when a surgeon takes skin, fat, and sometimes muscle from another part of the body and makes it into a breast shape). Whilst breast scars can still be hidden, horizontal or lateral incisions from the nipple may be necessary. In addition patients will have scarring at the tissue donor site taken for the flap, this is most often from the abdomen, upper back or rear buttocks.
Scar tissue from radiation therapy
After radiotherapy there is inflammation and damage to normal cells as well as cancer cells. These injured cells repair but the tissue is often hard and fibrotic causing a lumpy scar. Changes to the skin occur approximately 10-14 days after the onset of radiation treatment. The skin usually becomes red and inflamed and often darker in colour. This skin discolouration can last for months. Looking after the skin, minimising the inflammation and hydrating with an oil such as Bio-Oil and protecting the skin barrier can improve recovery.
Scars from lumpectomy
Whilst a lumpectomy is a smaller procedure, it is still likely to leave a significant scar. Due to the nature of the procedure which aims to remove a portion of breast tissue around the lump, the scar could be positioned in a highly visible area and can leave a depressed section.
Scar tissue lumps
Occasionally scar tissue can form lumps under the skin. These usually occur where scar tissue develops at the site where breast tissue has been removed. Suture granulomas can also occur when scar tissue forms around stitches. Given the sensitive nature of lumps in this patient group, it is worth making them aware that these can form and what to expect, however, it is always best to advise them to get any lumps checked. Scar tissue characteristics:
- Generally occur in the first few weeks after a wound has healed
- Will usually be located directly by or under a scar
- Will feel quite firm
- Can sometimes remain tender and red if the scar continues to be active i.e. a keloid scar and will usually require assessment and specialist treatment
Psychological impact of scars
A survey of 1,000 people with scars carried out by Bio-Oil, highlighted that 49% feel their scar affected their body confidence. Furthermore, one in five felt they might never fully accept their scar. Whilst breast cancer treatment is already a highly emotional time, it’s important not to underestimate the impact scars can have on an individual’s mental wellbeing and how patients may differ in their views. Some may see them as a symbol of survival, whilst others may see them as a constant reminder of a traumatic time.
Furthermore, in some patients concerns about their scars may have knock-on effects on other areas of their life such as forming relationships. In breast cancer patients, they might have concerns about intimacy and what their partner might think about their body.
You can help prepare the patient for the procedure they are undergoing by advising them on what to expect from their scar and providing information on wound and scar care to ensure the best possible outcome.
How to help patients care for their scars
There are five different types of scars: Keloid, hypertrophic, atrophic, contracture and striae. With the exception of keloid scars that may require specialist treatment, most can be cared for by the patient at home.
In all types of scarring, the skin will have long-term changes. Scar tissue doesn’t have the same dermal layers that form the skin’s structure. They will also lack hair follicles and sweat glands.
Patients may be shocked by the initial appearance of their scar. Talk to them about how their scar will change over a period of 12-24 months (post-epithelialisation stage of scar formation) as it starts to settle down.
There is a window of opportunity to help ensure a scar heals well. Factors such as bleeding, infection and wound opening up (dehiscence), as well as smoking, can disrupt the healing process.
To minimise bleeding, patients can be advised to:
- Firmly apply a dressing and bandage
- Apply pressure with a clean cloth or sterile gauze until bleeding stops
To minimise infection, patients can be advised to:
- Keep any dressings on unless advised to remove them
- Keep areas dry (damp dressings leave the area susceptible to infection)
- Wrap cling film over the treatment site when showering
- If the wound is exposed, salt water bathing daily is helpful
To minimise wound dehiscence, patients can be advised to:
- Take extra care before the stitches are removed
- Avoid vigorous exercise
- Avoid stretching the site
- Apply micropore tape or steri-strips to the site to help strengthen the area
Post-healing, patients can be advised to:
- Massage an oil or moisturiser into the scar daily in order to keep the scar hydrated and soften the scar tissue
- Apply silicone gels or sheets to the scar
- Wear a sun cream as sun exposure on new scars can cause pigmentation
- Clothing and bras
Patients may find that their bra rubs against the scar area. Once a scar has matured, this shouldn’t be an issue, but during the early stages advise them to wear a specialist post-surgical bra or choose a non-under-wired option.
If the scar isn’t healing, particularly if it is red and itchy and becoming more pronounced, patients should be advised to see their doctor. It may be that the scar is being over-active and topical treatments may be needed to reduce this activity.
Some women who have undergone a mastectomy may wish to have a tattoo to cover the area. Patients should wait at least 2 years to allow their scars to settle, use a tattooist who is experienced in working on scarred skin and follow the aftercare instructions carefully to avoid any risk of infection. It is advisable to check with their GP first.
Support for healthcare professionals
Bio-Oil has developed a patient guide including a CARE acronym to help patients understand their scars and how they can care for them during the scar maturation process.
Bio-Oil has produced a number of resources and a Revalidation CPD accredited training module ‘Managing Scarring in Primary Care’ for nurses to support Continued Professional Development and improve knowledge around the different types of scarring and how they should be treated.Take the free training.
 Thompson A, Kent G. Adjusting to disfigurement: processes involved in dealing with being visibly different. Clinical Psychology review. 2001;(21):663-82.