‘Breast reconstruction is an aesthetic failure achieved by surgical compromise’ – British journal of Plastic Surgery (1980)
Some days ago the American actress Angelina Jolie – yes, she really is ‘jolie’ – was featured on TV at her first public appearance after she had undergone breast surgery for cancer in February last. In an article in the New York Times about two weeks ago she announced that she had had a double mastectomy (removal of both breasts) after testing positive for a genetic mutation that put her at high risk for breast and ovarian cancer, and she had also had reconstructive surgery.
In the TV clip, she looked very well indeed, and said as much to a reporter who had asked her a question. She wore a black dress and to all intents and purposes she had ‘breasts.’ This kind of publicity by high-profile people is meant to encourage others who might be reluctant to undergo what could be considered as mutilation of their bodies, especially women who are very conscious of their body image. There are the pros and cons of such ‘coming out’ by celebrities, who no doubt do it with the best intention in the world.
An example of the beneficial fallout of such a move by a famous person is the stimulus given to stem cell research in the treatment of injuries to the spinal cord, which can leave a person paralysed. This was the case with ‘Superman’ Christopher Reeves, as a result of an unfortunate accident that he suffered while performing a stunt. He sustained a fracture of the neck with severe damage to the spinal cord, leaving him paralysed from the neck downwards, a condition known as ‘quadriplegia.’
But he was a fighter and survivor, and lived for ten years more before he succombed to a chest infection. In this period, however, he had gone on a campaign across America to create awareness about and raise funds for research into the new treatment that was showing promise for such conditions, i.e, stem cell research. If I am not mistaken, a chair has been set up in an American university to continue this work, and because of the courage, perseverance despite the odds and dedication of Christopher Reeves, many spinal-cord injury patients may stand to benefit in future.
But every injury or disease has its specificities, and what applies to one does necessarily apply to another. In the case of breast cancer, and the announcement by Angelina Jolie, some reservations have been expressed in the American press, while generally saluting her courage for her disclosure. This ‘was lauded by some advocates as a bold move that will inspire women to be proactive, learn about their family histories and risks, and consider genetic testing,’ However, ‘at the same time, some breast surgeons are discomfited that some might infer from the article that reconstructive surgery is a quick and easy procedure, and worry that Ms Jolie inadvertently may have understated the risks and potential complications.’ Not to mention access to and the affordability of such treatment.
The case of another patient who had undergone breast reconstruction was referred to. Although she was ‘pleased with how she looks’ 54-year old Mrs Roseann Valetti ‘is uncomfortable,’ all the time feeling ‘like I’m wrapped up in duct tape’ describing ‘the persistent tightness in her chest’ that many women report after breast reconstruction. She added that they ‘may look terrific to the eye … but it’s never going to feel like it’s not pulling or it’s not tight. It took me a while to accept that. This is the new normal.’
We all, male and female human beings, have a perception of what our bodies ‘normally’ look like, and wish that this ever remain so, even with the changes that accompany ageing. This ‘normal look’ is known to medical people and psychologists as the ‘body image’, and it includes all the visible parts of the body – down to the little toe. What I mean by this is that, although from an anatomical point of view one can do without the little toe, whenever it is proposed to a patient that for some reason (usually a vascular problem) the little toe needs to be amputated, this comes as a great shock, and the first reaction of most people is ‘no.’ Now what to speak of a whole foot or a leg? And when it comes to the face or the breasts, which give identity to the person, the situation is even more complicated.
I remember the case of a colleague’s mother when we were working at the SSRN Hospital in 1975. She was a 66-year old diabetic and had developed gangrene of the leg. She was in a very bad state, and to save her life amputation of the leg was necessary. But she was adamant, even when Dr Keating, who was the orthopaedic surgeon with whom I was working at that time, came to explain to her and try to persuade her, with me as the interpreter. Even her son, my colleague, and her family, couldn’t make her budge, and as was wont to happen, about 48 hours later she unfortunately passed away.
Such is the attachment we have to our body image, and as doctors we cannot force anyone to undergo any procedure but only explain in detail and advise. When it comes to the more sensitive parts of the body, especially the female breast which is considered as a symbol of feminity, the impulse to preserve or restore to as normal as possible is obviously much stronger. As is underlined in the ‘bible’ of Plastic Surgery by Converse (the 1977 edition which I used was in 7 volumes), ‘Deformities of the size and shape of this structure assume importance above and beyond those of a functioning secondary sexual organ. To have physically acceptable breasts is a normal desire, and the psychologic implications of such a desire must not be underestimated.’ (italics added)
The physically acceptable refers to only the appearance. What looks like a breast after a mastectomy is in fact not one. For the normal breast is made up, under the skin, of glandular tissue that produces and secretes the milk that comes out through the nipple, which is surrounded by the pigmented area known as the areola. These two constitute the ‘nipple-areola’ complex, reconstruction of which is more delicate and complicated after a total mastectomy that replacing the breast with, basically, a mound of substitute material.
This material can be of three types, fat and skin (from the upper abdomen or buttocks), fat and muscle (from the upper and lower abdomen, or from the upper part of the back on the same side as the breast that has been removed), or an artificial substance (silicone gel contained in a pouch that is placed under the – pectoral — muscle over which lay the breast, in a space created for that purpose). Before these techniques were developed, what was available was a foam breast prosthesis, which is still used by many women. It can be seen, therefore, that the glandular breast tissue cannot be replaced (so far), and hence the ‘surgical compromise.’
But why ‘aesthetic failure’? Simply because a reconstructed breast can never look exactly as the normal breast especially if only one side has been removed. As it is, to eyes trained in the surgical anatomy of the external form of the human body, even intact breasts have a certain degree of asymmetry. In reconstructed breasts this is certainly more apparent. But covered over by a bra and the overlying dress or blouse, the fullness that appears, as was seen when Angelina Jolie was shown, had all the look of breasts – surgically a mere mass of tissue or silicone gel placed there after a lengthy procedure that can sometimes necessitate several stages, and that may be attended by complications (infection for example) which prolong the reconstructive process further even in the best hands and the best centres. Women should be very careful about who they entrust their bodies to.
* Published in print edition on 7 June 2013