Skin care and scarring after breast cancer surgery and radiation therapy

The impact of breast cancer surgery and radiation therapy on skin is often overlooked though it can affect the way your skin looks and repairs itself. Skin changes can cause discomfort or pain and serve as a daily reminder of the trauma of breast cancer treatment.

In this interview, Living Beyond Breast Cancer CEO Jean A. Sachs, MSS, MLSP, spoke with breast surgical oncologist Monique Gary, DO, MSc, FACS, about ways to protect your skin before, during, and after treatment. Dr. Gary explains how doctors evaluate your skin before treatment and questions to ask. Learn how to minimize keloids and hypertrophic scars, and about specific products, lotions, and supplements that strengthen skin. Get guidance to protect your sensitive skin in the summer sunshine.

Watch, listen, or read the transcript below.

Monique Gary, DO, MSc, FACS
Dr. Gary is a board-certified, fellowship-trained breast surgical oncologist and medical director of the Grand View Health/Penn Cancer Network in Sellersville, Pennsylvania. She has served as director of the breast program there since its accreditation in 2015. She is the founder of the Cancer Genetic Risk and Prevention Program at Grand View Health, which provides genetic counseling and high risk management for those with a strong family history of cancer and those with known hereditary cancer syndromes. Dr. Gary would love to hear from you: Follow her on Facebook, Instagram, and Twitter.

Jean A. Sachs, MSS, MLSP

Chief Executive Officer, Living Beyond Breast Cancer

Jean began her work with LBBC in 1996 when she became the organization’s first executive director; she was named CEO in 2008. Jean brings a lifetime of women’s advocacy experience to her role as CEO. She lives LBBC’s mission everyday by speaking with newly diagnosed women about their needs and gaps in support. Read more.

 

Jean Sachs:

Hi, everyone. It’s Jean Sachs, the CEO of Living Beyond Breast Cancer. I hope everyone is staying safe and doing well. I am excited today that we have brought back one of our favorite speakers, Dr. Monique Gary, who is a breast surgical oncologist and the director of the breast program at Grand View Hospital, which is part of the Penn Cancer Network right here near us in Philadelphia. They’re actually based in Sellersville, Pennsylvania. So welcome, Dr. Gary.

Dr. Gary:

Thank you so much for having me. It’s so good to see you again.

Jean Sachs:

It’s great to see you. I know we haven’t talked in a few months, so maybe just tell us quickly: how are you doing?

Dr. Gary:

I’m doing well. Our health system is doing very well, as we’ve seen our numbers with respect to COVID-19 go down and down and down. And so we have spent a considerable amount of time now in our cancer program encouraging patients to begin resuming their screening again. And I can’t stress how very important it is, because we are seeing patients who have delayed their diagnostic imaging. But, also, it’s just so important to not neglect your breast care. And so I think that it is safe to go back to screening in many places, and almost every health system has taken very detailed precautions to make sure that it’s safe for patients to begin their screening again. So it’s time to get back to our breast health because, as you said, Jean, earlier, cancer doesn’t quarantine. It’s my favorite hashtag. And so I want patients to know that we are here for them, whether it’s virtually, whether it is in person, but if there is a breast issue, please, please come see us and do not delay. But now it’s time to start your screening again. So, that’s what we’re working on.

Jean Sachs:

Yeah. I’m so glad you said that. I actually went for my mammogram last week and was a little nervous but realized I always do it in May. And if I get too far behind, I’m going to forget. So I think if you are on a schedule, stay as close to that schedule as you can.

Dr. Gary:

Mm-hmm.

Jean Sachs:

But today we’re going to switch topics, and we’re going to talk about skin care and scarring because we want to continue to give our audience content that is relevant, important to them. So as a breast surgeon, I know you have conversations with your patients about skin care and scarring. And so what should patients expect?

Dr. Gary:

It’s a great question. And I think that a patient who is newly diagnosed and meeting with your surgeon for the first time really should expect a conversation, one, about where your cancer is and the surgical approach and your surgical options. But once you cover that and where your scar might be, it’s now time to start talking about other considerations for after surgery, for things like radiation therapy.

And so I have a very detailed conversation with my patients about their skin care, about their regimen. I look at the breast and the skin itself to see whether or not they have thick skin or crepey skin, whether or not they have hyperpigmentation, or if they have scars in other areas that are hypertrophic or keloids. And so I take into account all of those things. And I also have a very detailed conversation with patients about the size of their breast, because the more pendulous and large a breast is, those patients tend to suffer a little bit more of the side effects of radiation on the skin. And those are great candidates for things like [breast] reductions, which can happen at the same time as their cancer operation.

Jean Sachs:

Okay. So I’m going to ask you to do some definitions. So tell us, what is a keloid, and what is hypertrophic?

Dr. Gary:

Sure. So hypertrophic scars are scars that are potentially flat, but they are wider than the average scar. So, the collagen, it heals very quickly, and it forms a very wide and shiny scar, but it is not a thick and raised scar. So patients who keloid have a condition that has to do with their collagen cross-linking that causes them to have a scar that is knobby and much more rounded and more raised. And those are conditions that are really challenging to treat because sometimes we will remove those scars, and they tend to form balls of scar tissue. And when we know that patients form those types of scars, we want to make sure that we address their skin care really carefully, because surgically removing those tends to result in more of those.

So I just ask patients about how they scar so that I can better understand what type of incision and where to put that incision, because more than ever, I think it matters where we put patients’ incisions. They’re living longer with breast cancer. And I participate in something called the Hidden Scar Campaign. I’m a Certified Center of Excellence. And we want patients to move from the fear of breast cancer to the confidence part of it, and scars plays a real role in that. It can create lasting pain for patients as well. So, scar placement and that discussion is important to patients, not just for cosmesis.

Jean Sachs:

And is that a conversation a patient would have with their breast surgeon or with their plastic surgeon?

Dr. Gary:

Both because the breast surgeon is the gateway to the plastic surgeon.

Jean Sachs:

Mm-hmm.

Dr. Gary:

So I’m a breast surgeon who does oncoplastic techniques, and so I will do minor procedures for patients, what we call level one and two, moving nipples, elevating, creating symmetry, or matching for patients. But then plastic surgeons may do reductive procedures, lifts, and breast reductions. And so if you don’t offer that to a patient, they will not necessarily know to ask for it. But many patients are candidates for it, and most insurances cover it at the time of their cancer surgery and even in a delayed fashion.

Jean Sachs:

Okay. So everyone should ask about scarring before they begin their surgical process.

Dr. Gary:

… Sorry. Go ahead.

Jean Sachs:

No, I just want to make sure you define keloid as well.

Dr. Gary:

Yep. Sorry. Did we get that one?

Jean Sachs:

No.

Dr. Gary:

Oh. So keloids are an accumulation of scar tissue that is in a more raised and organized fashion. Many patients have an abnormality in their collagen formation that creates a type of scar that is a raised, lumpy pattern that’s not a flat scar, but it is a ball or a conglomerate of scar tissue.

Jean Sachs:

Okay, great. So, in your experience, can women expect that these scars will fade over time? Is there a rule of thumb? And then, depending on your skin tone, whether you’re lighter, brown, or black, what can people expect?

Dr. Gary:

So some scars do fade over time, and others do not. And I think what it relates to is multifactorial. And so, again, I think a good scar history with a patient, to ask how they have healed from other procedures, piercings, et cetera. Let’s see if I can answer your question. I’m sorry. I’m going back to read your question. Do scars fade?

Scars can fade over time, but there are things that patients can do in order to help the skin remodel to make their scars more faint. And so even postoperatively and even after radiation, I will see patients and we’ll talk about things they can do with respect to scar creams and moisturizers and massage that can help their scars, one, to release, because scars like to contract. They want to pull in, and that pulling in and that dimpling can cause chronic pain for patients. So getting scars to release but also getting them to fade requires some work [for] the patient after surgery. So some do and some don’t, but I think to a large degree, most patients’ scars can improve over time.

Jean Sachs:

Okay. So for both surgical scars or radiation burning, because I think these skin issues are connected, are there products you recommend? I know there’s a lot on the market. I think breast cancer patients are already overwhelmed with all the things they should get. So what are your go-to products?

Dr. Gary:

So during radiation, my go-to products, I encourage patients to use aloe, either natural aloe or aloe-based products that are more gel-based and cream-based than oil-based, because radiation, it’s a process that creates heat in the breast. And I comment to patients six months out, “Do you still feel heat radiating from one breast compared to the other?”

And they say, “Oh, I hadn’t noticed that, but I do.” And so cooling gels with aloe are very helpful. In addition to those hydrating gels, I recommend that patients consider things that have healing properties like calendula. Lancaster Farms has a wonderful healing salve that has calendula. It has vitamin E oil. It has lavender and essential oils in a combination and in a cream-based formula. And I find that that is very helpful for patients for their scars and also for the radiation burns.

Aquaphor is another sort of barrier cream for patients. And I encourage them to use this after their shower. So while you’re still wet, you can apply something that has more of an oil base to it to lock in the moisture.

Jean Sachs:

Mm-hmm.

Dr. Gary:

But using just oils in and of themselves are not going to give you moisture, and so patients need to be really careful using any significant amount of oil prior to radiation, because it will essentially add oil to something that’s being heated, and that can create more burns. And so during radiation, creams, moisture-based products after your shower, things that can lock in moisture with essential oils.

And I think patients should be really careful about applying essential oils directly because sometimes they can be very strong. Some of my patients use frankincense and others, and you want to just make sure that you’re not going to use something that will burn your skin further. So test somewhere on your body, and, again, think about moisture separately from oil and healing salves.

Jean Sachs:

That is so helpful. I think there’s been such an interest in coconut oil, which I love, but in the end, it is drying. It’s not as moisturizing. And you do want to really think about what is cooling and what is helping. But I think a big takeaway of what you’re saying is, be proactive from the beginning, right? Don’t wait until it gets worse.

Dr. Gary:

Absolutely right. As soon as your surgical scar has begun healing. So if I see a patient two weeks out, we’re removing their Steri-Strips or their Dermabond or whatever covering that I’ve put on their incision, and the next question, if they haven’t asked me, I say, “Well, now you should ask me at what point should I consider a scar cream or something for my skin?”

Jean Sachs:

Mm-hmm.

Dr. Gary:

And we talk about that. Two weeks from now, when your skin is a little less bruised, when your incision is healing even further, now you can begin to apply things like Mederma, which is a great scar cream, and vitamin E oil is another one that I recommend for patients because it’s not as expensive as some of the scar creams with the collagen in them.

But two to four weeks after surgery, you want to start thinking about just massaging that skin and massaging that scar a bit, because radiation will compound the contracture that surgery creates. When we create a space in the tissues, it’s going to do this, and your goal is to get that tissue to release over time. And radiation doesn’t really help it. It continues to make scars want to pull in. And so you have to manually combat that. And I tell patients, “Get into the habit of touching your scars, of knowing what they feel like, of rubbing and releasing your scar so that you won’t have chronic pain later on.”

Jean Sachs:

That’s great advice. And so this is something they should be doing not just two to four weeks after surgery but really just make it part of their routine.

Dr. Gary:

It’s true. And it becomes a part of your breast exam and just knowing yourself and spending that time with yourself. Because I find that the patients who don’t do it early on, some of them become afraid to do their breast exam because they don’t know what to expect. They haven’t felt the changes all along because the breast that’s been operated on, the breast that’s been radiated has some changes in the texture. The skin itself becomes thicker. The texture of the breast becomes a bit more doughy and sometimes leathery. And if you haven’t been feeling those changes, you’re going to maybe feel a lot of apprehension and anxiety about what your new breast exam is like once you’ve completed therapy. So I try to get patients to wrap their mind around performing that exam and really getting into it with their scars right after surgery.

Jean Sachs:

Great. I’m going to ask you a question you might not be able to answer, but I know a lot of women who, once they’ve healed, have decided to have tattoos.

Dr. Gary:

Sure.

Jean Sachs:

Artistic tattoos to cover up their scars or [some] people say, [to] turn something really ugly into something very beautiful.

Dr. Gary:

Mm-hmm.

Jean Sachs:

So if someone is thinking about that, is there a period of time they should wait before they meet with a tattoo artist? Do you have a rule of thumb there?

Dr. Gary:

I don’t think there’s any strict guidelines around how long a patient should wait after their treatment to pursue tattooing, but I think it really depends upon what procedures they’ve had done. So if you’ve had mastectomies, if you have to get post-mastectomy radiation, I think that you then will maybe consider a reconstructive process and where you are in that. So I think a good rule of thumb is that I would wait at least six months to a year after you’ve completed your final course of therapy to determine how you might like to proceed cosmetically with respect to tattoos because the skin does change and remodel over time. The scar tissue that is present does give over time, one year, two years, five years, and the texture of the skin will change.

Radiation can frequently result in some thickening and what we call edema, or swelling, some fluid, not just in places like the armpit, or the axilla, with lymphedema, but also in the dependent, or the bottom, part of the breast. Many women find that there’s a thickness and a leathery-ness and a heaviness because there is fluid within the layers of the skin, almost like phyllo dough. And so when there’s fluid in those layers, tattooing could be messy. You could have some challenges with retention of the ink, with leaking of that ink, with lymphedema and other issues. So I say a good rule of thumb, at least six months but probably a year before you consider tattooing so that you can understand what your skin is doing, what your scars are doing, and how well the integrity of your skin is intact to be able to manage tattoos.

Jean Sachs:

Right. And probably good advice, anyway, to give yourself some time to heal. So my final question is: we’re in summer, people are outside. So are there special things people who’ve had radiation or scarring, if they are wearing bathing suits and some things are showing, are there special things they should do to protect their skin? Should they actually stay out of the sun? What do you recommend?

Dr. Gary:

I recommend if you are during treatment to avoid unnecessary sun exposure and to always, always wear sunscreen, so an SPF, I would say, of at least 50, if not higher, even for women of color. So I think that there’s a misconception that perhaps women with more melanin don’t need to wear skin protectant and sunscreen, and you absolutely do. And at no time is it more important than when you’re undergoing radiation, because those radiation changes affect the cells in your skin. And those basal cells begin to die, and those melanocytes, as we call them, the pigment cells, rise to the surface. And that creates a darker skin tone for women of color. For Caucasian women, you see more pink and reddening of the skin. And the skin becomes very sensitive, one, during radiation but then after radiation, so sunscreen throughout. I recommend, again, moisture-based creams and hydration of the skin with subsequent oil application thereafter.

And it’s really important to keep the areas on the undersurfaces of the breasts dry. And so this is something that we don’t talk enough about, either. Women can get fungal infections along the mammary, the inferior or the inframammary fold. And so it’s important for women to use something like maybe a cornstarch. I would avoid talc, but cornstarch is a great one for drying. There are antifungal powders, like a nystatin powder, or a nystatin or a fungal cream that can prevent some of the itching and the redness. And so keeping the dark and moist areas dry. Some women use lambswool, even. And those are great ways to protect the skin. I would avoid underwire bras because the underwire can irritate the skin also. Not because it causes cancer but because of the irritation and the rubbing there. So, itching, zingers, burning of the skin is all normal after radiation, and so you really want to be careful if you are going into the sun to wear a hat, to wear sunscreen, to keep the important areas dry when you’re not in the water.

Jean Sachs:

Wow. That’s really great advice and all things that I think not many people are told and certainly not by their breast surgeon. So, again, why we are so grateful for Dr. Gary for just the range of issues you address and pass on to your patients. So thank you again for all you’re doing to help the breast cancer community, and thank you for always being available to talk to Living Beyond Breast Cancer.

Dr. Gary:

It’s truly my privilege. I did want to add one more thing.

Jean Sachs:

Yes.

Dr. Gary:

I find that magnesium-based creams, so mag sulfate, the Epson salts are also great things to soak in if patients are having significant discomfort, heat, and burning. So creams that have magnesium will be very helpful for the skin to remodel also. And I meant to say that earlier, so I want to make sure I throw that in there.

Jean Sachs:

Does that mean people should also think about taking magnesium?

Dr. Gary:

I think it’s a great supplement along with your calcium and vitamin D because it helps the absorption, and also a good hair, skin, and nails vitamin. Thanks for that, because I always encourage my patients when they’re starting chemotherapy [to] start taking a hair, skin, and nails vitamin now because chemotherapy affects the fastest-growing cells. The hair follicles, the nails, the skin changes after chemotherapy. And so even for radiation and just for good hair and skin health, a good hair, skin, and nail vitamin with vitamin A, biotin, vitamin E, and vitamin D are going to be great things for your skin. So, yes, and magnesium is a part of it, too.

Jean Sachs:

Okay. Again, more great advice. So I know we have to end, but thank you so much. And, as always, we want you to stay well and healthy, and we’ll definitely bring you back with another topic. And to everybody watching, thank you for tuning in to Living Beyond Breast Cancer. Remember, we have closed Facebook pages, so if you need immediate support, please go to our website, LBBC.ORG. We’ll be happy to join you into one of those groups, and you can also call our Helpline. We’re here for you. Stay safe, and stay strong.