During my decision-making process of whether or not to have a preventive double mastectomy based on my family history of breast cancer, my surgeon told me one fact that particularly distressed me: “You won’t be able to do push-ups after this procedure.”
As a personal fitness trainer and mother who prided herself on beating her teenage sons in push-up contests, the thought of not being able to do push-ups killed me. But it was broader than that. I knew his statement meant that my body wouldn’t be the same: There would be trade-offs. I would lose something. I kept reflecting on the risks of breast cancer, what an occurrence of it might mean to me and my family, and weighing those possibilities against the certainty of losing some upper-body function.
Cancer risk won out, and I had the surgery in December of 2013.
Three-and-a-half years later, I still cannot do push-ups.
And while I can eke out a few on my knees, my surgeon tells me that I shouldn’t. “Just don’t work your chest. It can do what you need it to do, but don’t purposely exercise those muscles,” he pleads.
I lost my chest strength not because of the mastectomies, but because of the type of reconstructive surgery I chose and the procedures my surgeon prefers to use when doing that reconstruction. If I had elected to forego reconstruction, I would now be beating my younger son in push-up contests. I would have regained my chest strength, kept my title as family push-up champion, and had a completely flat or even slightly concave chest.
I did the usual questioning: Am I being vain in wanting reconstruction? Shouldn’t I care more about my upper body function than the way I look? I’m always telling my clients that it’s more about feeling and functioning well than looking good. Then there was the flip side: I’m in my mid-40s. I like to look good. My husband cares. I opted for reconstruction.
Because of my body composition, I had few choices in terms of reconstruction.
I had very little body fat, so procedures such as a Deep Inferior Epigastric Perforator (DIEP) flap, which uses existing lower abdominal fat to form new breasts, were not viable options for me.
After looking into my available choices and consulting with my surgeon, I felt the best route was tissue expansion and permanent FDA-approved cohesive silicone gel (so-called “gummy bear”) implants. This reconstructive procedure involves inserting tissue expanders under the chest skin and muscle at the time of the mastectomy, my surgeon explained. Every couple of weeks thereafter, saline is injected through the skin into the expanders in order to gradually stretch the muscles and skin. Once the muscle and skin are stretched enough for the selected implant size to fit comfortably underneath them, another surgery is done to swap the expander for the implants.
The loss of chest strength in my case had two main causes.
One, the pectoralis major muscle was stretched over the implant. (The pectoralis minor remains untouched.) This is standard in this reconstruction method, my surgeon told me. An over-stretched muscle does not contract with as much strength as a muscle of normal length. Two, my surgeon prefers to denervate—the process of cutting of the nerve supply—the pectoralis major muscles in conjunction with inserting the implants.
My surgeon cut the two main pectoralis major nerves (the medial and lateral pectoral nerves) so that they cannot cause a forceful muscle contraction. The denervation gives a more natural appearance and prevents the implant from being consistently compressed and eventually displaced or distorted by the contraction of the overlying muscle. My surgeon described the purpose of denervation as “keeping the muscle, and therefore the breast, quiet.” If you don’t quiet it by cutting the nerves, the breast moves around whenever the overlying muscle contracts, a phenomenon called the “pectoralis effect.” Sometimes it moves upward, sometimes it moves out to the side, and sometimes it flattens…quite unnatural and a bit bizarre. It can be caused by activities as simple as shaking someone’s hand or picking up a glass of water.
In my case, my chest muscles were “quiet” for the first couple of months post-denervation. Then, maybe due to my high levels of physical activity, they began getting active again. My breasts would move up and to the outside when I'd perform certain tasks, because the muscles pulled them that way. I'd another surgery to locate and cut the active nerves again.
The experience of needing that second surgery solidified for me my surgeon’s instructions to not focus any exercise routine on the pectoralis muscles. If you do, you send a signal to your body. Your body replies, “Uh oh! My owner wants to do push-ups. I’m going to figure out a way to do it!” The denervated muscles may adapt to the demands you’re placing on them by re-innervating some parts of the chest muscle or increasing the use of the still intact minor nerve branches to recruit muscle fibers that previously weren’t engaged.
I rarely pine away for my lost chest muscles or regret my choice of having this type of reconstructive surgery. Most of my day-to-day activities remain unaffected. I can carry objects, shop, clean the house, run my kids around. Even walk on my hands (which requires a lot of shoulder and core strength. Surprisingly not much chest strength).
I miss my chest muscles mildly on three somewhat regular occasions.
One is during my own workouts. I simply skip all chest exercises. I miss them. I want to do full push-ups. I can’t. I’d like to do chest flys. I don’t. But I don’t ache to do those things like I thought I'd.
I also miss my old chest when I'm training clients and want to demonstrate an exercise that requires significant pectoral strength. Instead of a perfect demo, I give them an imperfect one and hope I provide an adequate verbal description.
Lastly, I notice the loss when I do yard work. Lopping shears and strong pec muscles go together. Bringing the handles of lopping shears toward each other basically requires performing a chest fly. Last spring, I injured my shoulder trying to cut through a thick branch with the lopping shears. Because I didn’t have the pec strength to do it, I recruited the smaller muscles in my shoulder. I injured myself. I’m still paying for it.
As a personal trainer and exercise physiologist, here’s my exercise advice to those who have had a similar surgery:
Continue working the entire body with the exception of the chest muscles. Those muscles still function to some degree. Not as powerhouse muscles. They can provide stabilization and small strength contributions to exercises. They perform well in endurance activities but not in activities requiring brute chest strength.
Be satisfied with the routine day-to-day tasks they can perform. When you come across a physical challenge that they can't meet, such as a 3-inch-thick branch, don’t push it. Leave it alone or allow someone else to handle it. It’s one of those situations in which you need to respect and accept your limitations. Luckily, you still have hundreds of exercises you can do for your lats, rhomboids, spinal erectors, traps, delts, biceps, triceps, forearms, abs, gluts, quads, calves, etc.
With the ever-increasing popularity of genetic testing, higher percentages of women will be faced with the decision of whether or not to have preventative mastectomies. Most women who opt for the surgery will have several reconstruction options available to them. Inform yourself in detail of what each method entails in terms of recovery, final appearance. Final function. Find a surgeon who comes highly recommended by trusted sources and who can show you a portfolio of his or her work. If you make a highly-informed decision, you're not likely to regret the outcome.
Tracy Hafen is a Michigan-based exercise physiologist with 15 years of experience in personal training and corporate fitness. She's authored and co-authored several publications related to fitness, diet. Exercise.