COSMETIC

Exercise after Breast Augmentation:

A Randomized Controlled Trial
Filipe V. Basile, M.D.

Background: There are limited scientific data regarding the impact of exercise
Thais S. Oliveira, M.D. after breast augmentation surgery. Recommendations range from a few weeks to
Ribeirão Preto, Brazil a few months of physical activity avoidance. To decide whether early exercise after
breast augmentation is safe, a prospective randomized trial was designed to mea-
sure complications, scar quality, and patient-reported outcomes in this setting.
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Methods: The present study was a randomized controlled trial to investigate

the effects of early exercise (1 week after surgery) on postoperative compli-
cations, scar quality, and patient-reported outcome (BREAST-Q). All women
undergoing primary breast augmentation surgery in the authors’ institution
were randomized to either standard restrictions or exercise. The three primary
outcomes measured were the presence of a complication and reoperation, scar
quality, and patient-reported outcome.
Results: A total of 225 participants were included in the final analysis. No
differences were found among the groups for age (p = 0.66), implant size
(p = 0.56), or implant pocket (p = 0.29); complication rates did not change
between the control (7.5 percent) and exercise groups (6.9 percent). When
assessed 12 months after surgery, the scar quality was comparable between the
groups (29.9 control and 29.6 exercise, p = 0.204). Intervention groups (exer-
cise) performed better on the BREAST-Q Augmentation Module: Satisfaction
with Outcome score (66.3 control and 83.4 exercise, p < 0.01).
Conclusions: Early exercise following primary breast augmentation does not
increase complication or reoperation rates or cause a reduction in scar quality
after 1 year. In addition, a patient-reported outcome showed improvement in
the exercise groups.  (Plast. Reconstr. Surg. 149: 18e, 2022.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

T
here are limited scientific data regarding the patient-based satisfaction research has shown that
impact of activity restrictions and exercise time away from exercise and time away from work
after breast augmentation surgery. There is are among the most important factors that are
no clear consensus of how long exercise should detrimental to patient recovery, especially among
be avoided after surgery, and there are no current the healthy and usually young cohort undergoing
evidence-based data to guide surgeons on this breast augmentation surgery.5–7
important aspect. Most plastic surgeons follow a To decide whether early exercise after breast
personal regimen based on their own experience augmentation is safe, we designed a prospective
that recommends a few weeks to a few months of randomized trial to measure complications, scar
physical activity avoidance. This recommendation quality, and patient-reported outcomes in this set-
is based on the belief that exercise could increase ting. Given the lack of knowledge regarding the
the complication rate, diminish scar quality, and
jeopardize surgical results. Recent data, however,
suggest that a decrease in exercise restrictions Disclosure: The authors have no financial interest
following surgery produced improved outcomes to declare in relation to the content of this article. No
in different surgical procedures.1–4 In addition, funding was received for this article.

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DOI: 10.1097/PRS.0000000000008676

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 Volume 149, Number 1 • Exercise after Breast Augmentation

beginning and duration of exercise interventions (bench press) of the shoulders; flexors (bicep
after breast augmentation surgery, this trial will curls) and extensors (triceps extensions) of the
provide evidence on whether exercise changes elbows; trunk flexors; hip extensors; and the
postoperative function and related outcomes. extensors and flexors of the knee. The exercise
program progression was based on American
PATIENT AND METHODS College of Sports Medicine guidelines8 such that
the participants completed three sets of eight
Study Design repetitions for each exercise at 80 percent of the
The present study was a randomized controlled maximal load that they could lift one time for that
trial to investigate the effects of early exercise (1 given exercise. If the patient experienced pain,
week after surgery) on postoperative complica- the load was decreased to a comfortable weight,
tions, scar quality, and patient-reported outcome and the exercise resumed. The maximal load
(BREAST-Q).5,6 The intervention period of this was determined for each patient during the first
trial was 12 weeks. After this period, patients were workout session and was defined as the maximum
allowed to resume their normal exercise regimen. weight the patient could lift without pain.
Our institutional review board approved In both intervention groups, the exercise
this trial. All patients provided written informed regimen was designed to maintain rather than
consent. increase physical fitness. Compliance with each
All women undergoing primary breast aug- intervention was calculated as the percentage of
mentation surgery in our institution who already possible exercise sessions completed. Patients
performed physical activity regularly were ran- with compliance under 50 percent were removed
domized to either standard restrictions (“avoid from the study.
high-impact activities such as running, aerobics,
and sit-ups for 12 weeks after surgery”) or exer- Surgery
cise (starting 7 days after surgery). The exclusion All of the surgical procedures were performed
criteria were secondary surgery and patients who by the same board-certified plastic surgeon
had not exercised regularly (defined as at least 45 (F.V.B.) working as part of an integrated, multi-
minutes, three times a week) in the past month. disciplinary team from 2017 to 2018. The incision
used and the details regarding the implant type
Intervention (Exercise Groups) and the pocket plane were gathered. Before the
Patients in this group followed a physical operation, the patients were informed about the
training program and participated in physical risks and benefits of their respective procedures.
activity three times a week for 12 weeks. Women Only textured silicone gel–filled implants
in the intervention group were further divided were used, all of which were from the same man-
into two arms: aerobic exercise and strength ufacturer (Allergan, Inc., Santa Barbara, Calif.).
training. Women in the exercise arm received The follow-up protocol used included visits at 1
specific orientation regarding frequency, inten- week; 1, 3, and 6 months; and 1 year after surgery.
sity, and type of exercise to be performed, as The patients were followed for at least 12 months
described below. after surgery.
In the aerobic training group, patients com- All of the patients were given a combination
pleted a 1-hour exercise session thrice weekly for of continuous pump-controlled propofol infusion
12 weeks. Each session consisted of a brief warm- and local anesthesia. A regimen of surgical steps
up and 30 to 35 minutes of walking or running at was maintained when possible. This regimen was
a rating of perceived dyspnea of 3 to 5 (moderate a modification of a previously described surgical
to somewhat hard) on the Borg categorical scale.7 technique.9 Decisions regarding placement of
If the patient felt pain, the intensity of the exer- the incision, volume, and pocket depended on
cise was decreased until they were comfortable. In the preferences of the patient and a tissue-based
some cases, this could mean walking fast instead analysis performed by the attending surgeon.
of running or eventually stopping exercising. All patients were discharged the same day as the
In the strength training group, patients com- operation. No drains were used. During the post-
pleted a 1-hour exercise session thrice weekly for operative period, we recommended the use of a
12 weeks. Each session consisted of a brief warm- supportive brassiere for 4 weeks. Patients in the
up followed by progressive strength training of exercise group were oriented to exercise using
the following major muscle groups: abductors a supportive brassiere. Antibiotics, pain medi-
(overhead press) and horizontal adductors cine (i.e., nonsteroidal anti-inflammatory drugs),

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Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • January 2022

and breast skin moisturizer were prescribed. No independent score from 0 to 100, with 0 corre-
enhanced recovery after surgery program was sponding to a bad outcome and 100 representing
used during the study. All postoperative orienta- the best possible outcome.
tions were identical in all groups, excluding orien- The database was constructed with Excel
tations concerning exercise. (Microsoft Corp., Redmond, Wash.). The quali-
tative variables are expressed as percentages.
Statistical Analyses Quantitative variables are expressed as medians
Patients admitted to the study were random- with ranges. The factors included in the analysis
ized to one of three groups: intervention group 1 were analyzed by standard analysis of variance
(aerobic exercise), intervention group 2 (strength or chi-square test when applicable. An addi-
training), or the control group. The randomiza- tional Kruskal-Wallis test was also performed on
tion sequence was generated by the study designer the BREAST-Q and Patient and Observer Scar
using a random number table. Assessment Scale scores.
The three primary outcomes measured were All p values less than 0.05 were considered sig-
the presence of a complication, scar quality, and nificant. Statistical analyses were performed using
patient-reported outcome (BREAST-Q score).5,6 R 3.0.2 (R Core Team; R Foundation for Statistical
The presence of a complication was defined as Computing, Vienna, Austria).
any event that required surgery, additional medi-
cation, or additional visits to the office until 12 RESULTS
months of follow-up.
Scar quality was evaluated after 12 months by Participant Characteristics
measuring using the Patient and Observer Scar A total of 258 female participants were ran-
Assessment Scale.10 The Patient and Observer domly assigned to the following groups: control
Scar Assessment Scale consists of two scales: the group (n = 86), intervention 1 (aerobic exercise,
patient scale, which contains six items, and the n = 86), and intervention 2 (strength training,
observer scale, which contains five items. All n = 86). Over the course of the study, eight partici-
items on the two scales are scored numerically. pants in the intervention group withdrew because
The patient scores the characteristics scar color, of health issues (n = 5, flu or unrelated illness)
pliability, thickness, relief, itching, and pain; the or inability to follow up (n = 3, long trip or city
observer scores scar vascularization, pigmenta- change); five participants in the control group
tion, pliability, thickness, and relief. Each item is withdrew because of health issues (n = 1, flu or
scored from 1 to 10, where 10 reflects the worst unrelated illness) or inability to follow up (n = 4,
imaginable scar or sensation and 1 reflects normal long trip or city change); and an additional four
skin. Lower scores indicate better scars. The same participants were lost during the control group
staff nurse applied the Patient and Observer Scar follow-up.
Assessment Scale to all patients. She was not aware Another nine patients in the strength group
to which group each patient belonged. and five patients in the aerobic group were
The third primary outcome measured was removed from the study because they could not
a patient-reported outcome. Patient-reported attend the minimum 50 percent of exercise ses-
outcome studies provide insight into patient sions to remain in compliance, as determined
perception of health status and satisfaction with prestudy. The main reasons for lack of compli-
interventions. In this study, we chose to use the ance were fear or insecurity focused on exercise
BREAST-Q Augmentation Module: Satisfaction (n = 5) and pain (n = 4).
with Outcome. The BREAST-Q, a validated The data from the 225 participants who com-
patient-reported outcome measure, quantifies the pleted the trial were included in the final analysis
impact of cosmetic and reconstructive breast sur- (75 in the control group, 75 in the aerobic train-
gery measured from the patient’s point of view.5,6 ing group, and 75 in the strength training group).
The BREAST-Q has been used in more than Table  1 shows data regarding age, implant size,
22,000 patients to demonstrate differences in and implant pocket among the groups. In all
patient satisfaction and quality-of-life outcomes. patients, an inframammary incision was used.
BREAST-Q Augmentation Module: Satisfaction No differences were found among the groups
with Outcome is specific to cosmetic surgery and for age (p = 0.66), implant size (p = 0.56), or
focuses on patient-perceived satisfaction with their implant pocket (p = 0.29) by using one-way analy-
surgical outcome. This module scale produces an sis of variance.

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 Volume 149, Number 1 • Exercise after Breast Augmentation

Table 1.  Baseline and Surgical Characteristics of

Patients
Age Implant Size Implant Pocket
Group Average SD Average SD SG (%) SP (%)
Control 26.5 5.9 309.3 58.4 33.3 66.7
Intervention
 Aerobic training 26.1 5.5 310.7 54.6 42.7 57.3
 Strength training 25.6 6.1 318.3 53 45.3 54.7
p 0.6661 0.5681 0.2912
SG, subglandular; SP, subpectoral.

Complications
Complication rates did not change between
the control and exercise groups. Furthermore,
none of the enrolled patients needed revision sur-
gery within the 12-month follow-up period, and
complications were generally minor, as shown in
Table  2. The complication rate for the control Fig. 1. Patient and Observer Scar Assessment Scale (POSAS) box-
group was 7.5 percent (n = 6) and 6.9 percent for plot. No statistical difference was observed between the control
the intervention group (n = 12). Implant malposi- and interventions group. The three lines that make up the box rep-
tion presented as mild superior migration of the resent, in this order, the first quartile (Q1), median quartile, and
implant and was managed with upper pole bras- third quartile (Q3); the vertical lines below and above the boxes
siere use with complete improvement. represent the variation expected in the data set. Observations
above or below these lines are considered outliers. The plus sign
Scar (+) indicates the average. An additional Kruskal-Wallis test was
also performed on Patient and Observer Scar Assessment Scale
When assessed 12 months after surgery,
scores, confirming the analysis of variance.
the scar quality (Patient and Observer Scar
Assessment Scale) was comparable among the
three groups, as shown in Figure 1. Detailed data regarding Patient and Observer Scar Assessment
Scale scores are shown in Table 3.

Table 2.  List of All Complications That Occurred BREAST-Q

during the 12-Month Follow-Up Period* When assessed 12 weeks after surgery, the
exercise group showed higher scores than the
Size of
Implant BREAST-Q control group. Analysis of variance showed that
Patient Group (ml) Age Score Complication both intervention groups performed better
14 Control 410 38 81 Asymmetry (p < 0.01) on the BREAST-Q Augmentation
20 Control 325 22 69 Nipple sensation Module: Satisfaction with Outcome score (Fig. 2).
change
24 Control 240 26 60 Ptosis/striae There was no difference between the intervention
30 Control 325 31 64 Redness groups. We also performed the Kruskal-Wallis
46 Control 260 20 55 Implant test. It returned the same results (Q scores were
malposition
56 Control 300 19 50 Breast firmness significantly different between the control and
84 Aerobic 325 26 100 Asymmetry
100 Aerobic 300 32 75 Nipple sensation
change Table 3.  Patient and Observer Scar Assessment
114 Aerobic 240 36 81 Striae Scale after 12 Months*
117 Aerobic 300 29 75 Redness
120 Aerobic 260 24 69 Pain Scar Assessment Scale (POSAS)
126 Aerobic 350 22 75 Breast firmness Group Average SD Minimum Median Maximum p
159 Strength 325 21 75 Nipple sensation
change Control 29.9 5.1 21 30 44 0.204
169 Strength 325 23 89 Asymmetry Intervention
189 Strength 410 27 89 Ptosis  Aerobic 30.4 5.7 21 30 55
191 Strength 280 31 81 Breast firmness  training
195 Strength 300 25 85 Pain  Strength 28.8 6.1 16 28 55
206 Strength 380 28 81 Nipple sensation  training
change POSAS, Patient and Observer Scar Assessment Scale.
*The presence of a complication was defined as any event that required *All groups had similar score ranges. No statistical difference was
surgery, additional medication, or additional visits to the office. observed between the control and interventions groups.

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 Plastic and Reconstructive Surgery • January 2022

routinely counseled their patients to avoid physi-

cal activity to protect their results, this finding
may seem counterintuitive. One possible explana-
tion is that exercise is not much different from
daily activities that are essentially unavoidable,
such as climbing stairs, standing up, or reaching
for an object. Another explanation is that preco-
cious mobilization of involved muscular groups
and articulations might be beneficial, which has
been extensively shown in other kinds of surgical
procedures.1–4,11 Many examples of this rationale
are available in the literature. A recent Cochrane
meta-analysis concluded that early exercise may
diminish the impact of the sequelae of criti-
cal illness in the intensive care unit setting, for
instance.12,13Another randomized controlled trial
showed that early mobilization and exercise were
Fig. 2. BREAST-Q boxplots. These charts help highlight the dif- associated with the same complication rates as
ferences among the groups. The intervention groups had a delayed mobilization after hip fracture surgery.14
significantly better BREAST-Q score (p < 0.001). An additional More surprisingly, a recent meta-analysis that eval-
Kruskal-Wallis test was also performed on the BREAST-Q scores uated the safety and efficacy of aerobic exercise
confirming the analysis of variance. The three lines that make up commenced early after cardiac surgery (as early
the box represent, in this order, the first quartile (Q1), median as 4 days postoperatively) showed that aerobic
quartile, and third quartile (Q3). exercise commenced early significantly improved
functional and aerobic capacity following cardiac
intervention groups, p < 0.001). Detailed data surgery, while adverse event rates did not differ
regarding the BREAST-Q score are shown in significantly.15,16 The same principle (early postop-
Table 4. erative exercise is beneficial and does not increase
complication rates) can also be found across sev-
eral surgical fields, including orthopedic surgery,
DISCUSSION pelvic surgery, and head and neck surgery.1–4,11,17
When assessed 12 months after surgery, rates One could infer that, if this is the case in such set-
of complications and scar quality were compara- tings, the same should be observed after breast
ble between patients who started exercising early augmentation surgery in healthy patients. Our
(1 week after the procedure) and patients who randomized controlled trial presents evidence in
did not exercise until 12 weeks postoperatively. this direction.
The kind of exercise (i.e., aerobic or strength The most unexpected among our find-
training) did not matter. To plastic surgeons who ings was the fact that women in the interven-
tion arm reported better self-reported outcomes
(BREAST-Q scores). There was no difference in
Table 4.  BREAST-Q Augmentation Module: results, however, if the exercise performed was
Satisfaction with Outcome Scores after 12 Weeks*
aerobic or strength training. The authors believe
BREAST-Q Score that the better self-reported outcomes could be
Group Average SD Minimum Median Maximum p attributed to the effect that exercise has on mood
Control 66.3 7.6 50 64 100 <0.001 and quality of life in general.18–20 The relationship
Intervention between improvement of mood and exercise shows
 Aerobic 83.3 10 64 81 100
 training that individuals who regularly exercise experience
 Strength 83.6 11.2 55 85 100 a better mood pattern than those who do not.
 training Experimentally controlled exercise withdrawal
*The intervention groups had significantly better BREAST-Q scores has adverse consequences for mental health.21,22
(p < 0.001). The control group had a BREAST-Q score ranging from
50 to 100, with an average score of 63. The aerobic training group A recent meta-analysis showed that exercise with-
had a BREAST-Q score ranging from 64 to 100, with an average score drawal consistently resulted in increases in depres-
of 83.3. The strength training group had a BREAST-Q score rang- sive symptoms and anxiety.23 Exercise withdrawal
ing from 55 to 100, with an average score of 83.6. Tukey test results
between groups were as follows: aerobic versus control, p < 0.001; physiology is a vastly researched field. Although
strength versus control, p < 0.001; aerobic versus strength, p = 0.981. the mechanisms underlying the relationship

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 Volume 149, Number 1 • Exercise after Breast Augmentation

between exercise and mood are not completely CONCLUSIONS

understood, several pathways have been involved The most important finding that these data sug-
in mediating these changes. Prevailing theories gest is that early exercise following primary breast
posit that augmented hippocampal long-term augmentation in patients who are already exercis-
potentiation, hypothalamic-mediated cortisol ing does not increase complication or reoperation
levels, and hippocampal corticosterone changes rates or cause a reduction in scar quality after 1
are the most relevant.24–26 Experimental studies year. In addition, a patient-reported outcome
showed that these changes were also significantly (BREAST-Q Augmentation Module: Satisfaction
related to changes in interleukin-6 concentration with Outcome) showed improvement when mea-
in both the blood and central nervous system.27 sured at the end of the intervention (12 weeks),
These findings help explain the lower BREAST-Q reflecting the negative effects exercise withdrawal
scores in response to short-term exercise with- might have on healthy subjects as well as the ben-
drawal after breast augmentation. The authors eficial effects exercise has on mood and psycho-
should note, however, that the improvement on logical well-being. These findings are in line with
the BREAST-Q questionnaire in the interven- a broader tendency recently seen in other surgical
tion groups is possibly transitory. Further studies fields in which early exercise was shown to be safe
should be performed to evaluate whether such an without increasing complication rates.
improvement could be sustained if the question-
naire were administered 1 or 2 years after surgery. Filipe V. Basile, M.D.
Professor Joao Fiusa Avenue, 2300
One important limitation of this study is that 14024230 Ribeirao Preto, SP, Brazil
only patients who are already physically active and [email protected]
perform exercise were analyzed. Caution must be Instagram: @drfilipebasile
applied to extrapolate these findings to patients
who do not perform exercise regularly. Exercise
withdrawal will most likely not be seen in seden- REFERENCES
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