“When I saw the word ‘metastatic’ on my pathology report, I thought I was dying—that it had spread everywhere,” Kara recalls. “In truth, it is metastatic locally, meaning in my lymph nodes, but breast cancer is a whole other medical world to me.”

Kara opted for a double mastectomy, preceded by 16 weeks of chemotherapy. In the days and weeks leading up to her surgery, Kara tried to stay active. But with the physical ups and downs of chemotherapy, her routine certainly wasn’t as rigorous as it had once been. She did three days a week of “scaled down” strength-training, trying to be gentle with her body and taking as much rest as she needed.

So, by the time she was two weeks post-op from her mastectomy, Kara was itching to tie up her sneakers and hit the street. The only problem: She’d been given very little guidance about how to safely start reincorporating exercise.

“I was discharged the same day as my surgery, and my surgeons had me meet with a physical therapist before I left. They gave me a piece of paper with exercises you would tell your grandma to do!” Kara says with a laugh. “‘Put your arms to the side and do tiny arm circles!’”

At home, Kara tried doing her own research. “I was Googling the timeframes for certain activities: When can I run? When can I lift three-pound weights? I would’ve loved to have just a little more guidance on what to do to start building my strength back up.”

Meet the Experts: Marcella Fornari, DO, is a breast oncology surgeon at Atlantic Breast Associates in New Jersey. Sam Ciacci, PA-C, CSCS, a New York-based fitness specialist and founder of Bell Mechanics.

If a literal doctor isn’t sure how to get back into fitness after a mastectomy, what’s the average woman to do?

The Big Exercise Question Mark

The road to recovery after a mastectomy is different for every woman—and is heavily influenced by the type of reconstructive surgery she’s undergone, according to Marcella Fornari, DO, a breast oncology surgeon at Atlantic Breast Associates in New Jersey.

If a woman chooses to go flat (a.k.a. not have implants), that’s typically the “easiest” surgical option in terms of recovery, Dr. Fornari says.

The next level up would be a mastectomy with implants, which is typically a four- to six-hour surgery, and often entails inserting temporary implants (called expanders). Over time, this creates space for the actual implants, which will be swapped in after about three months. Most patients will be sent home the day of their surgery.

The third option, which has the longest recovery time, is a DIEP flap reconstruction, which uses the patient’s own tissue (typically from the abdomen) to form the implants. That surgery typically takes eight to 10 hours and has a hospital stay of one to three nights.

Once discharged, a patient is usually able to move around and care for themselves—within reason, says Dr. Fornari. “What I tell my patients is, you’re fully functional in that you’re going to dress yourself. You can go to the bathroom by yourself. You can eat. But you’re not doing anything strenuous. You’re not reaching up high for anything. You’re not scrubbing floors. You’re taking it easy.”

During recovery, some women may work with a physical therapist to begin gently gaining mobility and flexibility in their upper body, as many report feeling tight after surgery.

“What people with the expanders will tell me is it feels like they did a thousand pushups, or it feels like they have two bricks on their chest,” Dr. Fornari says. “It feels tight and makes you want to hunch over to keep those muscles on top of the implant from being stretched out.”

Typically, about four weeks post-op, women will be cleared to resume exercising their upper body. But what that should look like remains under-studied.

“I don’t know anything in the literature that even looks at that,” Dr. Fornari says of how to return to exercise post-mastectomy. “Even in our training, it’s not like there’s anything in our textbooks or in fellowship that we focused on.”

This lack of knowledge leaves women vulnerable—and at potential risk of injury. If she goes too hard too fast at the gym, she could, for instance, pop a stitch, resulting in a hematoma (a.k.a. a pooling of blood) that could necessitate returning to the operating room. (Though this is rare, says Dr. Fornari, it is something to be mindful about.) Less dramatically, she could be left with general swelling or soreness.

Dr. Fornari’s blanket advice: “You just have to listen to your body. You’re not going to go back in and go straight back to where you were. Ease yourself in, and if it doesn’t feel good, then step back and work yourself up again.”

Trial and Error Leads to Epiphany

Intuitively, Kara began following a similar approach as she got back into running.

“I started walking three days after surgery—just up the street and back, very slow,” she says. She waited until her four-week post-op check-in to pick up her pace to something resembling a run.

“I was finally like, I’m just going for the run,” she says. “I think it was a 16-minute mile. I could have walked it faster, but it just felt good to move.”

Kara kept building up her stamina and distance. One day she was able to run 5k without stopping. Then she quickened her pace, notching 15-minute miles instead of 16.

“I’ve just been slowly adding, going up to four miles or trying to work on going a little faster,” she says.

In the strength-training department, she’s taken a similar trial-and-error approach. Right now, a tricep dip—which had been part of her typical routine prior to surgery—seems intimidating, so she’s swapped in tricep kickbacks instead. Bicep curls with 15 lb. dumbbells feel good, so she’s doing those too. “I just want to feel like I have my strength back,” Kara says.

That need to reclaim her strength and feel at home again in her body is a familiar one to Sam Ciacci, PA-C, CSCS, a New York-based fitness specialist and founder of Bell Mechanics. Sam underwent her own double mastectomy in February 2023, following a stage one breast cancer diagnosis.

And just like with Kara, Sam was sent home with scant information about how to get back into fitness following her surgery.

Sam Ciacci, a New York-based certified strength and conditioning specialist and founder of Bell Mechanics, underwent a double mastectomy in February 2023, following a stage one breast cancer diagnosis.

“I was told for the first two weeks, don’t lift anything heavier than five to 10 pounds and don’t go overhead,” she says. “Then, once I got the clearance at about four to six weeks, I could return back to activity. That was it.”

Sam heard similar stories on her breast cancer message board, which planted the germ of an idea. As a personal trainer with a background as a clinician, maybe she should be the one to create a program for women just like her.

“There’s no guidance,” Sam says. “I’m not accepting the [recommended] wall walks or little range-of-motion exercises. I don’t think that’s enough.” After all, she reasons, the shoulders and arms are connected to the rib cage, so it doesn’t make sense to work them in isolation. Instead, Sam incorporates moves that mobilize the entire torso.

As she began working weights back into her regimen, Sam took copious notes of what worked and what didn’t. After a year of tinkering, tweaking, and tracking, a structured fitness program emerged, which she called HER Journey. The 12-week program, which incorporates both strength and cardio, takes women through three progressive four-week phases, each building towards the next.

The healing phase focuses on mobility and range of motion. “You’re not having to lift heavy weights,” Sam says. “You’re just doing reps and getting the volume in. You’re getting back into your squats, into your presses.”

Next comes rebuild, which begins focusing more on strength-training. “That is more loading—or decreasing the reps and increasing the weight,” she says.

Finally, comes empowerment, which adds explosiveness to the movements. “The new exercises that they learned, we’re going to do it with heavy weight and we’re going to work on doing it fast,” she says.

The program is designed to be done with a handful of equipment like bands, dumbbells, kettlebells, and medicine balls. And while it’s meant to take three months, Sam stresses that there’s a lot of flexibility built into the plan. If a woman feels like she needs an extra week or two in the healing phase, for instance, she can take it. The program is about building both strength and confidence.

“I really want to educate through this program, so women feel empowered and confident to know, I can lift this weight, if I do it safely and do it correctly based on how Sam’s teaching it—and I can go heavier,” Sam says. “That is when the transition from a fragile to an anti-fragile mindset begins to happen.”

And a woman can feel like her body is, finally, once again her own. One user who tested Sam’s program said that the plan made her feel more confident.

“The program was easy to follow and progressed at a speed that didn’t feel overwhelming but was still challenging,” she says. “I was so happy to see the difference it has made in just one week and I’m excited to continue this journey.”

Amy Wilkinson is an entertainment editor who also specializes in health and wellness. When not editing or writing, she can be found teaching Pilates as a comprehensively certified instructor.