Strength training considerations post-top surgery
by: Maddie Mcelfresh
Disclaimer: I am not a doctor! Some of this article is anecdotal and based on my own experience. ALWAYS consult with your individual surgeon, listen to your body, and use your best judgement when deciding which activities to engage in after top surgery.
Top surgery is a gender affirming and life-changing procedure for many trans-masculine individuals. The removal of a major source of gender dysphoria leads to a reduction in dysphoria and depression, and increased body confidence and quality of life. While top surgery is generally a positive experience, the acute effects of any surgical trauma can be disruptive and jarring, oftentimes leading to post-op anxiety and depression. And, for competitive athletes or someone who exercises recreationally, the required period of inactivity following top surgery can be psychologically challenging and can exacerbate depressive symptoms. Many post-op individuals will scour the internet in search of solutions and advice and end up receiving mixed information and potentially dangerous recommendations. My goal is to provide a resource that takes into consideration the physiology of the wound healing process, the recommendations of various surgeons, and my own experience as a weightlifter.
Top surgery is the common term for a bilateral mastectomy, which plastic surgeons can perform in several different ways. The three most commonly performed procedures for FTM individuals are keyhole, periareolar, and double incision. More information on the differences between procedures can be found on the Gender Confirmation Center website. I will be focusing on the most common and most invasive “double incision” procedure.
To begin, should you exercise before top surgery?
Absolutely. In general, physical activity leads to better physical health, which sets you up for a faster recovery and more favorable healing outcomes. Additionally, regular exercise has repeatedly been shown to improve mental health. You want your body and brain to be as healthy as possible going into surgery. Finally, resistance training, specifically of your pectoral muscles, can improve your results aesthetically. The more defined your pecs are before surgery, the better your surgeon’s roadmap for optimal scar and nipple placement.
When can I start exercising again after surgery?
Day of surgery: Contrary to popular belief, top surgery recovery should not have you completely bed-ridden for weeks. Even on the day of surgery it is recommended that you go on short, easy walks to prevent swelling and blood clot formation in your legs.
Week 1: During the first week, your body is in the “inflammatory” stage of healing, and the damaged tissues are relatively fragile. It is critical to avoid any arm movement over your shoulders or lift anything more than 5lbs. Excessive activity in the first week puts you at risk of incisions opening, nipple graft loss, and aesthetic deformities. During this week, you’re not only wrapped up in post-op compression with drains coming out of your armpits, but you’re also on your physician-prescribed post-op antibiotics and painkillers. You probably won’t want to exercise much anyways. Light walks only at this point.
Week 2: Your body is transitioning to the “fibroblastic repair” phase. Scar tissue is being laid down but is still pretty fragile (about 10% of its final strength). Continue with walking and static stretching only. Movement will increase blood flow and oxygenation to the surgical site, encouraging an optimal healing environment. Walks will also be extremely important for your mental health at this stage to help mitigate the effects of cabin fever and get you outside. I would highly encourage static stretching, specifically of your lower body and your neck. While you have an actively healing wound on your chest it will feel safer to reduce tension on the wound and revert to a more hunched over position. However, trying to maintain good posture and stretching out your neck can prevent long-term postural problems and shoulder, neck, or back pain.
After 2 weeks: This is where surgeons begin to disagree. The tensile strength of your incision starts to increase rapidly between weeks 3-5 as stronger collagen is laid down. The strength of the incisions is still only at about 50%. Keep in mind, top surgery involves only the disruption and removal of breast tissue, skin, and fat. The underlying muscle tissue remains intact. Heavy lifting or stretching the arms above your head is still discouraged, but light cardio and even some lifting can resume. According to Dr. Ramineni, most activities can resume after 2 weeks. Dr. Mosser says to wait 3 weeks before doing light cardio. Dr. Garramone says to wait 6 weeks for any activity. While your incisions are still getting stronger and the upper body is mostly off-limits, this would be a great time to start to incorporate some lower body movements, such as bodyweight squats, split squats, RDLs, good mornings, safety bar squats, and belt squats. Make sure you have a friend to help load plates for you if you’re doing anything plate-loaded. You could even do some light movements of the upper body that are isometric or don’t involve large ranges of motion. Examples of these would be a plank, pallof press hold, low rows, or a dumbbell raise to shoulder height (no higher). I started doing belt squats at 3 weeks and graduated to the safety bar at 4 weeks, at which point I also incorporated some 1-arm dumbbell floor press.
5-6 weeks: By 6 weeks, your incision is made up of strong collagen fibers and is extremely unlikely to be disrupted; the tensile strength is approaching 80% of normal skin, which is usually as high as it gets when it comes to scar tissue. At this point, you can do more vigorous cardio and can begin lifting using larger ranges of motion. Start incorporating the bench press, rows, and push ups, and continue with lower body lifts as well. You could even start to load plates for yourself.
What about overhead movements?
When it comes to lifting your arms over your head, there’s quite a range of opinions. Dr. Ramineni and Johns Hopkins say full range of motion is ok at 4 weeks and Dr. Garramone says 6 weeks, whereas Dr. Mosser says to wait a whole 6 months to even raise your arms above shoulder level. Most other surgeons fall somewhere in between there. So what’s the deal, are your incisions healed by 6 weeks or are they not? To most plastic surgeons, the more conservative the better; they want to reduce the risk of scar stretching and bad aesthetic results. In a surgeon’s perfect world, you would keep your arms below shoulder level, reduce all possible excess tension on the scars, and have perfectly thin and faded scars. The big question is though; how realistic is this? And is later really better?
A case for more range of motion during recovery
For someone who lifts regularly, cessation of regular exercise can exacerbate post op depression symptoms. There is no right or wrong answer as to exactly what date you can perform your first bench press or do your first handstand post-op. It all depends on how YOU feel physically and mentally. You should weigh your personal pros and cons of possibly sacrificing aesthetics for the psychological and physical benefit brought on by exercise. Some people can make it months without exercising and be fine. But some, like NCAA swimming athlete Schuyler Bailar accept the risk of sub-par aesthetic results by returning to sport as soon as possible (for Schuyler, about 7 weeks post-op). I started performing the Olympic lifts such as snatch pulls and cleans around 6 weeks, but waited until 3 months to do explosive overhead movements like split jerks or full snatches. Moreso, there has been research to show that placing therapeutic mechanical stress on a healing wound encourages proper collagen formation and makes the scar tissue stronger. The same research suggests the mechanical stress applied episodically to a wound as early as 3 weeks encourages gains in tensile strength. Muscles only get stronger if you work them; the same applies to skin. Finally, if you’re someone who has had shoulder or back pain in the past, waiting longer than necessary to re-introduce range of motion to your upper body can lead to long term muscle shortening, pain, and poor posture.
After 6 weeks, the healing-time curve starts to plateau and only small additional scar strength gains are made up to month 3, but continue up to a year post-op. By month 3, it would do more harm than good to continue to restrict upper body movement.
The bottom line is that you should be patient, listen to your body, and take it slow, but also know that while your chest will feel super fragile, your incisions are stronger than you think they are.
REFERENCES:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2903966/
https://pubmed.ncbi.nlm.nih.gov/30286047/
https://pubmed.ncbi.nlm.nih.gov/10513902/
https://genderqueer.me/2011/02/26/post-surgical-depression/
https://www.genderconfirmation.com/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174176/
https://www.westendplasticsurgery.com/west-end-plastic-surgery-center-for-gender-affirmation/
https://drgarramone.com/pdf/apsipostopinstructions.pdf
https://pinkmantaray.com/top-surgery-recovery