Bra Ladies? Not on Your Life!

By Rhonda F. Turner, PhD, JD, BOCPO
Breast-prosthesis scanner technology. Photographs courtesy of the American Association of Breast Care Professionals (AABCP).

One in eight.

By now, that statistic is all too familiar: according to the 2009 American Cancer Society, one in eight women will develop breast cancer. However, through a battery of treatments, including various types of surgical mastectomy, targeted chemotherapy, hormone therapy, targeted biotherapy, radiation, and customized nutrition, 89 percent of the 200,000 women and 77 percent of the 2,000 men diagnosed this year with breast cancer will call themselves survivors. And as the survival rate steadily rises, the need for post-breast-cancer and post-mastectomy products, treatments, and services become increasingly necessary to enhance quality of survivorship and of life.

The first known mastectomy in North America was performed in Canada in 1700 AD. What is a mastectomy? Today, a mastectomy is defined as the surgical removal of part or all of the breast, surrounding tissue, muscle, and lymph nodes that are diagnosed as cancerous. Surgery types range in scope and complexity from a biopsy, a procedure in which a sample of suspicious breast tissue is removed and examined by a pathologist, usually for the presence of cancer; a lumpectomy, which removes only the cancerous portion or tumor; to a radical mastectomy, which removes the breast, chest muscles, and all of the lymph nodes under the arm. These surgeries can leave extreme malformations that must be replaced with a custom or a pre-fabricated breast prosthesis.

Breast Prostheses—It's Not Just About Aesthetics

Replacement of an amputated breast with a properly fitted breast prosthesis is not just an aesthetic concern, it is also a physiological one. Clinical conditions inherent to physiological imbalance, similar to those seen with extremity amputations, are evident in breast amputations as well. Compensation issues including lower back pain, spinal and disc issues, temporomandibular joint disorder (TMJ), and headaches can occur with either an improperly fitted breast prosthesis or no internal reconstruction efforts. To avoid long-term chronic issues, a breast prosthesis—whether through internal reconstruction or a properly fitted external breast prosthesis—is necessary to restore and maintain physiological balance. Other clinical concerns, such as chronic lymphedema, also factor in when providing post-mastectomy services.

In order to receive a properly fitted external breast prosthesis, both male and female breast cancer survivors have turned to experienced post-mastectomy fitters. And just like other professions within O&P, the post-mastectomy profession and the scope of practice of the post-mastectomy fitter have evolved over the past 25 years. So, what is a certified fitter and what does she do? Certified fitters provide post-mastectomy services, which begin immediately after amputation, oftentimes in the hospital. Breast-care services continue through several stages until the client receives a definitive silicone breast form. Post-mastectomy services also include follow-up appointments and replacements.

The Role of the Certified Fitter

In the United States, there are currently more than 4,000 women who hold post-mastectomy certifications from either the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) or the Board for Certification/Accreditation, International (BOC). A unique aspect of the breast care profession is that many of the certified fitters are closely and personally aligned with breast cancer. Whether as a survivor or as a family member or friend of a breast-cancer survivor, they have an acute understanding of the disease and the issues that surround it. Many entered into the profession to "give back" or, as one 15-year post-mastectomy fitter says, "I'm here to help them heal." However, being a certified fitter involves much more than "putting on a bra and stuffing it." More than 70 percent of post-mastectomy fitters are breast-cancer survivors, but it is their training, education, and experience that make them professionals.

According to a recent American Association of Breast Care Professionals (AABCP) survey, more than 85 percent of breast-care professionals work in either a post-mastectomy or hospital boutique. These boutiques are more than just "lingerie shops." Over the past quarter century, they have evolved into highly specialized licensed and accredited facilities that provide unique allied health services found virtually nowhere else in the prosthetics profession. Just as each client is an individual, so too the services provided to each client must be customized to meet her or his unique needs.

Tools of the Trade

A certified fitter uses a number of tools—the most basic one being the tape measure. The use of measurements combined with knowledge of chest-wall anatomy, surgery type, and the cancer-treatment process comprise the bulk of the tools in the certified fitter's arsenal. The final tool, however, is arguably the most important—the ability to listen. Combining these specialized tools with a familiarity of the various product lines is key to achieving a proper fit for post-mastectomy clients and providing them with balance and physiological symmetry.

Just as the knowledge and tools of the post-mastectomy fitter have evolved, post-mastectomy product lines also have evolved over the years. Silicone breast forms became widely available in the United States in the 1960s. Before that, women used cotton, fabric, corn bags, and even buckshot to fill the space. The original silicone forms were amoeboid and heavy. To this day, most people think of a silicone breast form as a heavy, hot, ovoid or triangular, off-pink "blob" of silicone. And while that was still the case 20 years ago, recent technological advances in materials, manufacturing methods, prefabricated shapes, and designs provide breast-care professionals with a surprising number of treatment options. There are approximately 15 different breast-form shapes, each with its own appropriate use depending on the concavity of the chest wall, sensitivity, and other factors. One of the newest additions to breast-form technology is the Massage Form™ by American Breast Care, Marietta, Georgia. This breast form incorporates silicone gel channels that provide a massaging action when worn.

Technology Improving Fit and Compliance

While aesthetics may not factor into the clinical reasons for replacing an amputated breast, that does not mean aesthetics should not be a consideration at all—we are human, after all. To provide flexibility in clothing choice and encourage client compliance, the bra is no longer the only way for clients to enjoy the benefits of a breast form. Additional attachment methods include "sticky" silicone and magnets. Similar to outer silicone coverings for prosthetic arms and legs, color injection in prefabricated forms and silicone color-matching in custom breast forms is now available. This provides a closer match to the client's skin tone, increasing likelihood that the client will wear the form.

Another integral aspect of fitting a post-mastectomy client is to properly fit the breast form's "carrier." For women, this is the bra; men usually opt for a chest-wall attachment or a specialized garment. According to a study published in the Chiropractic & Osteopathy journal, 80 percent of women wear incorrectly sized bras (Wood K, Cameron M, and Fitzgerald K, "Breast size, bra fit, and thoracic pain in young women: a correlational study." Chiropr Osteopat. 2008;16(1): published online 13 March 2008).

While this is true, it's not usually a medical issue; however, when providing a non-custom breast form post mastectomy, the carrier or bra must be fit as close to perfectly as possible. The certified fitter must take many factors into consideration when measuring and fitting for this type of garment. Without a proper fit, effective use of a breast form is diminished.

There have also been exciting technological advancements in the custom breast-form arena. Unlike upper- and lower-limb prosthetic devices, which are necessarily custom products, it is only recently that the custom breast form has become available and even more recently that computer-aided design and computer-aided manufacturing (CAD/CAM) have been used to create custom breast prostheses. ContourMed, Little Rock, Arkansas, has developed technology that allows the Omega™ Tracer CAD/CAM system from Ohio Willow Wood, Mt. Sterling, Ohio, to quickly and safely scan the chest wall to produce a non-invasive and accurate representation of the remaining breast. This representation is then carved and reproduced at the ContourMed facility as a custom breast form. Custom breast forms are especially appropriate for specific types of clinical presentations that may not be adequately serviced by a pre-fabricated breast form.

Post mastectomy is a necessary specialty. The breast-care industry has evolved into a unique union of tried-and-true techniques, with consideration, compassion, and technological advancements, allowing certified fitters to provide the best and most appropriate care to their clients.

Rhonda F. Turner, PhD, JD, BOCPO, is the president of the AABCP. She can be reached at or on Twitter at SpeakOutAABCP.