To breast or not to breast

On the principality of the plastic surgeon

Dear Global Jigsaw Community,

I’ve been toying with writing about the breast reconstruction process for a while . But I needed to see the long process through before I could bring myself to share the (trigger alert) unvarnished details. This started out as a humorous piece and ended up as polemic - but I think the all-over tone only reflects the all-overness of illness and recovery.

Before reading further, do consider becoming a paid subscriber to this writing venture that I call the Global Jigsaw. You could also gift a subscription to someone who might enjoy it. A present of words and ideas is always a good one - light to carry, heavy in meaning. :-)

xxx

In a cancer hospital, solemnity comes in a smorgasbord of shades. Patients emerge from their oncologists’ offices in weariness, shock, anger, grief, resignation. Out of the corner of their eyes, the cancerous weigh each other up. Is she wearing a wig? Is he going to break down?

But there is one corner in this Kingdom of the Sick, which feels distinctly more, “when life gives you lemons, make lemonade,” or put another way, “when life gives you a mastectomy, get ‘better’ breasts.” This is the principality of the Plastic Surgeon. It’s the area where waiting patients hear chuckles emanating from within the closed doors of the consultation room. Its where the doctors look like movie stars, and even old ladies exit tittering. It’s the candy shop of cancer.  

But it is precisely this atmosphere, the light-heartedness about “enhancements,” the idea that cutting away breasts equals ‘bad,’ while implanting new ones equals ‘good,’ – that speaks to something worrying about our society: its fetishization of female chests, and the almost public decision making over individual female bodies. When you are diagnosed with cancer, the shock and speed with which treatments progress means there is a certain automaticity to your decisions. The Doctor speaketh and the patient submiteth.

Yale University sociologist and co-editor of the forthcoming book, Interpreting the Body, Anne Marie Champagne, has written about how breast tissue isn't just physiological matter. "Breasts are medicalized, legislated, gendered, politicized and highly sensitized fleshy matter riven with public as well as deeply personal meanings," she says. Our choices around them "may be individual and motivated by personal aims, beliefs…but they cannot help but be impacted by society at large.”

When I had dwelt in the Kingdom of the Well, I would have considered buying a new pair of earrings far preferable to shelling out for a new body part. But there is nothing like amputation to change priorities.

This is where I need to insert a trigger warning for the corporeally squeamish. Details, you might prefer to remain innocent of, are about to be gone into. Bewilderingly, in retrospect, I wasn’t au fait with the details myself. My primary surgeon had simply suggested I go in for a mastectomy with “immediate” reconstruction. The immediacy of the phrasing had appealed in the moment. It had a mitigating effect on the horror of the imminent amputation.

In fact, as I discovered, both “immediate” and “reconstruction” were misnomers for an extended  process that involved multiple surgeries and depressing side effects, all to end up with a NippleandSensation – free,  mound of flesh, stretched across the mastectomy area to mimic the shape of a  breast, slashed through with a wide scar, and bearing about as much resemblance to a Pamela Andersonesque-bikini bod, as Harrison Birtwistle to Beethoven.

A photo of me at the hospital a day after my mastectomy, October 2022

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My first conversation with the plastic surgeon had begun charmingly. He didn’t seem solely preoccupied with my disease. He told me I had “cute shoes.” In matter of fact, I did. I had purchased the neon green footwear with patterned yellow butterflies a year ago, while on vacation in Barcelona. But no one – MRI technician, oncologist, surgeon, radiologist, anesthesiologist – had commented on these cuties before. Plastic surgeons have an eye for the aesthetic.

As the appointment progressed, I had to strip from the waist up and pose in various directions as the doctor took photos of my breasts. That this was done with both my husband and a nurse present, didn’t do much to alleviate the awkwardness of a strange man displaying such interest in my mammaries.

Photo-session over, a discussion ensued involving enhancing the “volume” of my bosom.  When I demurred, insisting that I just wanted the one breast reconstructed to its original proportions, the doctor sorrowfully asked, “if I was sure, sure.” When I repeated that I was, he shrugged, adding that I could always change my mind later.

Next, he moved on to my un-mastectomied breast, which surprisingly – to me - proved to be as much an object of interest as its malignant twin. The plan for this one, the doctor explained would be to, “put it back in its original place.” This euphemism for lifting my saggy old boob felt slightly insulting but given the probing and puncturing my body had suffered by this point, saggy boobs came in low in the hierarchy of affronts. Once again, I rejected the offer and once again, the surgeon reiterated that I could change my mind further down the road. For it was going to be a long and winding route.

It transpired that like the majority of women who are likely to have post-mastectomy chemo or radiotherapy, the only thing immediately inserted into the cavity left by mastectomy, is something called a tissue expander. This is essentially an empty implant placed behind the pectoral muscle, directly after the removal of the breast.

Following this surgery, I had to visit the hospital every few weeks over the next six months to have the expander inflated with saline, which was delivered through an enormous syringe directly into the implant. My “breast” was a deflated balloon, which was gradually pumped and plumped up into the desired shape. As the expanders filled, they stretched the tissue and caused new skin to grow, so that eventually there was enough to cover the final implant, which was swapped with the expander during a second surgery.

Adjuvant treatments like radiotherapy can interfere with implants, and so it is necessary to wait for a safe period after these treatments have ended before the final reconstruction can take place.

For me, the path to Surgery-II, eight months after the expander had first been placed, had been pot-holed. At every appointment for “expansion,” there had been the terror of the approaching needle, followed by a degree of pain. Submitting to the vulnerability of exposing my body to harm, in the name of health, had required suppressing my fight or flight response, an effort that left me depleted. There had been a loss in the range of movement of the shoulder, and a feeling of pins and needles in my upper arm. The breast “mound” was totally numb. Worst of all, I was stuck with the mental image of my breast as a Turkey being fattened for some insalubrious end.

But gradually, my expander filled, my chemo ended, and we arrived at a point when it was time to discuss and schedule the final reconstruction, wherein the expander would be swapped out for the permanent implant.

At my pre-op consultation, the plastic surgeon reiterated his offer to increase the cup size, which once again, I declined. Next, he told me I could have some fat taken out of my stomach and injected into the cleavage to give it a more rounded, pleasing look. I passed. But the irrepressible medic continued with his offerings, this time focusing on the healthy breast.

The fact was that as the expander had been pumped up over the months, my chest area had begun to resemble a geometrical instrument. The “real” breast was way down south, while the “fake” one thought it was on a teenager’s body, giving everything a triangulated look. And so, to my plastic surgeon’s delight, I agreed to a lift on my other breast, to make it symmetrical with the implanted one.

Forward five months and I have survived a minor post-surgical complication on the “healthy” boob, wherein the wound had delayed healing. The tightness in my shoulders and weakness in my pectoral muscles continues. However, one thing everyone agrees on, including my husband, is that I look sexier than ever before (with my clothes on), and I suppose I concur. The reason is that having higher, firmer breasts makes the body look more youthful and isn’t this what society tells us is the ultimate goal for women?

Breasts are considered so important to female emotional well-being that insurance pays for reconstruction post mastectomy in many countries. Mine was covered. And plastic surgeons and oncologists aggressively promote breast reconstruction as a way for women to feel whole again.

And yet, something that no one informed me about was that women who opt for breast reconstruction after a mastectomy have a strikingly high rate of complications. According to one study,  a third of women develop postoperative complications over the two years following a reconstruction, while one in five require more surgery than anticipated. In 5 percent of cases, reconstruction fails all together.

But doctors persist in pushing this surgery on women. I believe it is in good faith, given the deeply held belief that a flat chest will damage a woman’s sense of self. Doctors merely reflect our broader social priorities in focusing on physical appearance over the toll that long reconstructive procedures can take on women’s bodies and psyches.

Recently, there have been a number of investigations highlighting the refusal of some surgeons to accept the decision of patients opting out of reconstructive surgery, on the grounds that they will probably change their mind later. There have been instances of someone awakening from a mastectomy to find that unwanted flaps of skin and tissue have been left behind by doctors who are convinced that the patient will likely ask for cosmetic surgery in the future, when they are “calmer.”

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I’m not prone to regret. It’s always felt like a waste of time. And so, I do not regret having had the reconstruction and lift. There was humour in some of the process: the topless photo shoots could be quite funny. The surgeon was terribly earnest in showing me all the shapes and sizes of the implants I could choose, and my husband I often giggled over these recollections once we were back home.

I am looking pretty good these days when clothed and I’ve noticed more men doing that thing when they look at my chest before looking at my face. It can feel flattering. Or annoying. Depending on the day.

In the end it’s been a journey, and like all true voyages it has involved some admixture of loss and gain. However, we should pause, all of us, to think a little about the general brouhaha that boobs seem to elicit. The only thing that comes close to it, is women’s hair. But that’s a topic for another day.

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That’s it for now. Until soon,

Pallavi

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