What is post-mastectomy pain syndrome?

Neuropathic pain in the chest wall and axilla after breast surgery — **Neuropathic breast pain:** pain may involve the scar, chest wall, axilla or medial arm. Illustrative image.

Post-mastectomy pain syndrome (PMPS) describes persistent pain in the breast, chest wall, axilla or arm after oncologic breast surgery. Many definitions use pain lasting beyond three months, although research definitions vary.

Small sensory nerves may be cut, stretched or trapped after mastectomy, lumpectomy, axillary dissection, reconstruction or cosmetic surgery. A painful neuroma or scar entrapment can result, but PMPS may also be multifactorial.

Features suggesting a nerve source

Burning, stabbing or electric-shock pain.
Severe sensitivity to light touch or clothing.
A precise scar point where tapping reproduces an electric pain.
Axillary or medial-arm pain after lymph-node surgery.
Aggravation with arm elevation or scar stretch.
Pain with numbness or unpleasant sensation in a previously numb region.

Potential nerves include T3–T6 intercostal cutaneous branches and the intercostobrachial nerve, usually T2.

Diagnosis

Oncologic recurrence, infection, seroma, implant or capsule problems, radiation fibrosis, lymphoedema, shoulder disease, myofascial pain and cervical radiculopathy must first be considered.

Pain and sensation are then mapped, scars examined and a focal Tinel sign sought. A targeted local-anaesthetic block may help identify the responsible nerve; temporary relief supports localization but does not guarantee surgical success.

Nonoperative treatment

Management may combine pain medicine, neuropathic-pain medication, shoulder and chest-wall physiotherapy, scar care, desensitization, psychological support and targeted blocks. Fat grafting has been described, but results are not uniform.

Surgical options for localized nerve pain

Neurolysis: release of an intact nerve trapped in scar or fibrosis.
Neuroma excision and reconstruction: when a distal sensory target can be identified.
Targeted muscle reinnervation (TMR): connection of the proximal sensory nerve to a small motor branch.
Regenerative peripheral nerve interface (RPNI): placement of the nerve end into a small free muscle graft.

TMR principle connecting a sensory nerve to a small motor branch — **TMR principle:** a sensory nerve end is connected to a nearby expendable motor branch; the exact nerves and muscle depend on anatomy.

Technique selection depends on the nerve, neuroma, available target and previously operated or irradiated tissue. Breast-region evidence for TMR and RPNI is still developing and is largely based on small series.

Who may benefit from peripheral nerve assessment?

Assessment is appropriate when pain persists beyond expected healing, follows a scar or nerve path, includes focal Tinel tenderness or allodynia, and limits sleep, clothing, touch or shoulder movement despite conservative treatment. Coordination with the oncologic and reconstructive teams is used when required.

Read separately about breast and nipple sensation restoration

References

Bejar-Chapa M, Caragher SP, Gfrerer L, et al. Diagnosis and Management of Neuropathic Breast Pain. PRS Global Open. 2024;12(12):e6266. doi:10.1097/GOX.0000000000006266
Broyles JM, Tuffaha SH, Williams EH, et al. Pain after breast surgery. Microsurgery. 2016;36(7):535–538. doi:10.1002/micr.30055
O’Brien AL, Kraft CT, Valerio IL, et al. Targeted Muscle Reinnervation following Breast Surgery. PRS Global Open. 2020;8(4):e2782. doi:10.1097/GOX.0000000000002782
Kokosis G, Chopra K, Darrach H, et al. Re-visiting post-breast surgery pain syndrome. Gland Surgery. 2019;8(4):407–415. doi:10.21037/gs.2019.07.05

Post-mastectomy Pain Syndrome and Neuropathic Breast Pain