Postmastectomy pain may affect 20% to 68% of patients, yet many feel expected to "deal with it" after cancer treatment. When nerve injury is part of the cause, peripheral nerve surgery offers ways to address it.
Dr. Ziv Peled, a plastic and peripheral nerve surgeon at Peled Plastic Surgery in San Francisco, California, presented Peripheral Nerve Approaches to Chronic Breast Pain at Plastic Surgery The Meeting 2026, organized and hosted by the American Society of Plastic Surgeons (ASPS), in Houston, Texas. He described the physical and psychological burden of pain and numbness, including a profound sense of disconnect from the body. "A lot of times, people, specifically women, really feel alone in this process," he said.
He defined postmastectomy pain syndrome as pain lasting more than 3 months after surgery. It may feel electric, burning, or stabbing, or present as a dull ache. Possible contributors include nerve injury during mastectomy, radiation or chemotherapy effects, fibrosis, lymphedema, central sensitization, recurrent disease, and psychological factors. Dr. Peled argued that nerve injury may be part of the picture for many patients.
Finding the Painful Nerve
Workup starts with a history covering prior operations, pain onset and character, and treatments tried. Examination may reveal tender points along the anterior axillary line, often involving nerves from T2 to T6. A diagnostic nerve block can then test whether a specific nerve, such as the T5 intercostal nerve, is responsible. Substantial relief helps confirm the source and guide treatment. He also cited a study by Dave Brown and colleagues on intercostal sensory neurectomy for chronic mastectomy pain.
Treating the Nerve and Supporting Recovery
Injured nerves can adhere to an implant capsule, and the injured end may look abnormal. Dr. Peled advised following the nerve back until it appears healthy. "Resection should not be restricted for fear of creating a bigger gap," he said. Stopping too soon may leave unhealthy tissue that compromises a repair or leaves a painful nerve end.
When reconstruction is not feasible, options include a regenerative peripheral nerve interface (RPNI), targeted muscle reinnervation (TMR), a vascularized muscle target, muscle burial, a nerve cap, neurectomy, and proximal resection with coaptation. Some can be combined; the choice depends on the nerve.
Improvement may take 1 to 2 years, especially when the nervous system has become sensitized. He described controlled sensory rehabilitation exercises, including visualization, aimed at regulating sensation. Increasing sensation alone could worsen hypersensitivity.
For patients told that their pain is an unavoidable part of recovery, Dr. Peled presented nerve injury as a possible source worth investigating.
Key takeaway: Dr. Peled's approach to postmastectomy pain lasting more than 3 months combines a targeted history, examination along T2 to T6, and diagnostic nerve blocks to identify a nerve source, followed by resection to healthy nerve, nerve-end management, and sensory rehabilitation.