American Society of Plastic Surgeons
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Redefining beauty: The intersection of post-mastectomy reconstruction choices and femininity

the intersection of post-mastectomy reconstruction choices and femininity

The relationship between women and their breasts is deeply intertwined with concepts of womanhood, femininity and gender identity in our world. Thus, the impact of breast cancer and mastectomy goes far beyond the physical. To shed light on this complex issue, we recently had an insightful Q&A session with Ron Israeli, MD, FACS, who brings a wealth of experience and knowledge to this conversation.

His journey into the field of plastic surgery coincided with a pivotal moment in the understanding and treatment of breast cancer. Israeli notes how societal standards and medical practices have evolved significantly, creating a transformative landscape for breast reconstruction as he reflects on the past few decades.

ASPS: How have societal standards and medical practices related to post-mastectomy breast reconstruction evolved over the past few decades?

Dr. Israeli: In the past, breast cancer and treatment for breast cancer wasn't a topic that was given much attention by the media or national healthcare agendas. But that changed in the 1990s. If you remember, there was quite a famous New York Times Magazine cover article in 1993. The title of the article was "You Can't Look Away Anymore," and it included the image of a well-known model wearing a dress that came across her chest, obliquely covering only her one remaining healthy breast. The other side was an exposed mastectomy scar. This was sort of a pivotal point when we began to have more of an open conversation about breast cancer and mastectomy. Unfortunately, at that time, breast reconstruction was not always covered by insurance companies. What happened in 1998, one year after I went into practice, was that the Women's Health and Cancer Rights Act was passed on the third Wednesday of October that year. Breast Reconstruction Awareness Day, which is now on the third Wednesday of October every year, recognizes the passage of that law.

So that was a huge shift because all of a sudden, there's this increased demand for breast reconstruction, and it's covered by insurance. I'm only one year into practice at that point, and I have an interest in breast reconstruction as well as an interest in microsurgery. The practice that I joined then, with one of my partners now, Dr. Randall Feingold, was one of the first in the country doing microsurgical free flap breast reconstruction. It became a self-fulfilling prophecy that our practice increasingly focused on breast reconstruction as we were offering something that was new and provided better outcomes. I think that since then, breast reconstruction has really become a subspecialty within plastic surgery, and there have been very rapid advances. Most of what I do today I wasn't even trained in when I was a resident. Also, the mastectomy operation has become less invasive; we're not doing radical mastectomies anymore. The norm has become skin-sparing, nipple-sparing and nerve-sparing mastectomies.

To explain societal shifts, let me tell you about one of my patients early on in practice who had mastectomies with DIEP flap reconstruction and was able to convince Self Magazine and Allure Magazine to show her reconstructed breasts. In fact, I should mention her name is Beth Silverman, and she was an ASPS Patient of Courage in 2007. This was again part of the evolutionary shift. She was able to convince the editors of these magazines to allow them to show photos of her topless with her reconstructed nipples exposed... that was unprecedented at the time. And since then, we're slowly shifting the conversation. Breast cancer, mastectomy and breast reconstruction are not taboo topics anymore.

ASPS: Besides the traditional implants that we typically associate with reconstruction, are there any other innovative or lesser-known breast reconstruction techniques that might offer different benefits or aesthetics?

Dr. Israeli: Instead of going under the muscle in the subpectoral plane like the traditional implant approach I was trained in, we now do most of our implant reconstructions in front of the muscle. This allows us to have a less invasive operation since we're not elevating the pectoralis muscle, and the breast implant, now on top of the muscle, is located where the natural breast was before the mastectomy. This approach avoids unsightly animation, which can be uncomfortable. Other relevant and relatively new approaches relate to how mastectomies are done.

Breast surgeons and plastic surgeons are now collaborating during mastectomy not only in preserving the nipple-areola but also in preserving sensory nerves. We're learning that repairing nerves that are cut during mastectomy, either primarily or with nerve grafts, can increase the chance of sensation coming back while minimizing the risk of postmastectomy pain syndromes. So I think there's a transition into thinking beyond just reconstructing the breast shape but also allowing patients to have a more functional outcome with less pain and more sensation.

ASPS: What are the most common factors influencing a woman's decision to either undergo breast reconstruction or completely opt out of it?

Dr. Israeli: I think if a patient opts out of breast reconstruction, there is attention to detail that makes even the closure of a mastectomy a reconstructive procedure. But the decision for reconstruction is a very personal decision. There are a number of factors that I see in my practice. One relates to the patient's age and health. There may be more women who are older who might opt not to have reconstruction as we traditionally consider it and might opt to have either aesthetic flat closure or a simpler approach to reconstruction as compared to younger women. Decision-making may also be affected by available options depending on whether a woman has sufficient tissue for flap reconstruction. Patients might come into the office thinking, "I don't want to have implants, so I can't have breast reconstruction." They may not realize that they have a flap option as an alternative. I think seeing a plastic surgeon early on in the process is critical in decision-making so that patients can best understand what their options are.

Another factor relates to the decision of how to handle the opposite breast. For a woman diagnosed with breast cancer on one side, does she want to do a risk-reducing mastectomy on the opposite side? It can be a question of symmetry. If you treat one side with a mastectomy and reconstruction, the best symmetry, of course, would be if you also treat the other side with a mastectomy and reconstruction. But more often than not, it's an issue of wanting to avoid the risk of cancer in the opposite breast. When a woman has breast cancer on one side, the risk of getting cancer on the other side is not insignificant. The anxiety associated with having to still go for mammograms and to continue close monitoring might push patients to decide to have mastectomy and reconstruction on the opposite side, and that's a really significant factor for most bilateral reconstructions.

ASPS: How do your patients typically describe the emotional journey, the experience, when considering or undergoing breast reconstruction post-mastectomy?

Dr. Israeli: I'm not sure that there's any typical description – let's put it that way. Every patient is different. But one thing that we tend to see with all patients is that there's the fear of cancer coupled with the fear of mastectomy. Knowing that there are options for reconstruction can frequently help alleviate some of the anxiety early at the time of diagnosis. And that's why there's a significant benefit to having a plastic surgeon specializing in breast reconstruction involved early after diagnosis. It allows patients to understand their available options, helping them in their decisions regarding mastectomy with or without reconstruction.

The emotional journey is something that's very important for us to appreciate, and I realized this early in practice with my partner, Dr. Randall Feingold. We realized that mastectomy and breast reconstruction are not one-and-done procedures. There's an emotional component that must continually be addressed from the time of diagnosis to recovery. And we genuinely don't have the bandwidth to be able to properly handle that with our patients. That's why we recruited an individual experienced in counseling breast cancer patients to work with us in our practice. She spearheaded our Patient Empowerment Program, seeing every patient who comes in for breast reconstruction consultation to assess their emotional needs. If their emotional situation is such that they might benefit from individual therapy, she can refer them to an outside therapist. If she thinks that they might benefit from support groups, we have our Patient Empowerment Program Sisterhood of Support group. Realizing that caregivers can also have an emotional journey, we provide them with a dedicated support group if that interests them. We also have our Parent-to-Patient Caring Team. These are women at various points in their recovery journey who make themselves available to speak with newly diagnosed women to answer their questions and provide them with emotional support.

ASPS: How do you approach discussions with patients about managing expectations, the potential risks and the likely outcomes of the reconstruction?

Dr. Israeli: One of the important things that I discuss with patients from the get-go is that breast reconstruction is an inherently staged process. The best outcomes we achieve typically require more than one operation. In the past, when I was in training, we rarely did immediate reconstruction. Women had mastectomies, they healed and then they might come back for reconstruction at a later time.

The expectation now is that reconstruction can be done, and in most cases should be done, at the time of mastectomy. If a woman starts with two breasts when she goes under anesthesia for surgery, the understanding is that when she wakes up from the mastectomy, she will have breasts that are reconstructed. Many women might be thrilled with the outcome and happy with their immediate reconstruction, let's say with a direct-to-implant approach or a flap reconstruction, and they may not want to have any further surgery. It's dependent on what their expectations are. But in most cases, I would say that women will proceed with secondary, typically minor revision procedures to maximize the quality of their outcome.

As far as risks are concerned for somebody who has more than one option, we'll talk about risks related to implant reconstruction versus risks related to flap reconstruction. Those risks are a little bit different. We talk about the general risks of surgery, such as infection, bleeding and wound healing problems that apply to every operation I do. But with an implant, you're adding that additional dimension that, over time, that implant needs to be monitored and the appearance of the breast will change, and patients need to know that they might need additional surgery in future years.

ASPS: How does the physical recovery from breast reconstruction compare to the emotional healing and acceptance of the new body image?

Dr. Israeli: I think that physical recovery is more linear and predictable. If a patient has a DIEP flap, I know they'll be in the hospital for two days. They are going to go home with their drains. Within a week, I will see them in the office. There is a certain expectation that they will be progressing with their physical recovery within a predetermined time frame. This may vary based on their age, their physical health and the extent of the surgery they had. I know that I will send most patients for physical therapy provided by a therapist specializing in mastectomy recovery. It's all very predictable.

On the other hand, emotional recovery for patients and their caregivers is less linear and less predictable. We have to be very attuned to that with our patients and their families. In our practice, having another practitioner, as we have with our Patient Empowerment Program, is very helpful in addressing emotional recovery issues.

ASPS: Have you encountered a patient who regretted their initial decision regarding reconstruction? And if so, how do you address revisions or changes?

Dr. Israeli: I think that we try to avoid that. And we do that with a very careful discussion at the time of the initial consultation. For example, if a patient is unsure about whether or not she wants to have a flap reconstruction, if they're sort of on the fence, I tell them, "Let's not do it. Let's proceed with an implant approach for now. If we do that, we haven't burned any bridges." So, with this kind of open discussion, there is less risk of regret. With the example I gave, if we proceed with the implant reconstruction, the patient later has all the options available to her, and this will minimize the risk of regret. She can always come back and say, "I changed my mind. I decided I'm not comfortable with my implant reconstruction." We can then go back once they've recovered and either do a flap reconstruction or remove the implants to do an aesthetic flat closure.

I've certainly encountered patients who have regretted their decision, but I try to avoid that in my practice by making sure that I properly educate them before surgery. I think the most common encounter that I have with a patient who might have regretted their decision is a patient who might present to me for revision surgery. Somebody who's had a type of reconstruction that they may not be comfortable with. Through the years, as things change in their lives, perhaps after 5-10 years, these patients finally feel comfortable seeking additional opinions to proceed with revision surgery. The regret for many women in this scenario is that they didn't proceed with revision surgery earlier.

I'm sure you've heard the saying that beauty is in the eye of the beholder. I'm going to add dimension to that. I think that beauty is in the "mind of the beheld." What you think about the way that you look and the way that you feel is much more important than what others think about the way that you look. I think that it's more important for a woman to be comfortable with her decision and with how she looks and feels before she considers what other people might think of her. Including this in the conversation with my patients can affect their decision to have different types of reconstruction or even revision surgery.

ASPS: Can you share a particularly memorable case? Where a patient's choice around breast reconstruction deeply impacted their journey towards redefining their sense of beauty and self-worth.

Dr. Israeli: Let me tell you more about Beth Silverman, the patient I mentioned earlier. She presented to me in 2005 at age 26 with the diagnosis of an aggressive breast cancer requiring treatment with neoadjuvant chemotherapy. She had an appointment to see me for consultation, but on the day of her appointment, she didn't show up. We called to find out why and discovered that she had to be hospitalized to treat complications from her chemotherapy. At the end of my day in the office, I took my laptop, drove to the hospital and went to her hospital room to introduce myself. I did her consultation with her lying in bed while she was getting treatment, and I think that made a huge difference for her. I'll never forget what she told me. She said, "I would rather die than lose my breasts."

She had sufficient tissue for DIEP flap reconstruction, and after we did her mastectomies and reconstruction, she became an incredible advocate in the breast cancer and breast reconstruction community, helping countless women through their decision-making process as well as through their recovery. She was an ASPS Patient of Courage, specifically for her work helping other women from diagnosis to decision-making to recovery after reconstruction.

ASPS: With ongoing advancements in surgical techniques and shifting societal perspectives on beauty, as we've discussed with the Allure magazine. Where do you see the future of post-mastectomy breast reconstruction headed?

Dr. Israeli: Wouldn't it be great if we found a cure for breast cancer? Breast reconstruction would then be a thing of the past. So that's the hope. I think that the trend now continues to be creating and implementing less invasive approaches to achieve more natural outcomes. Whether it be prepectoral implant approaches, nerve-sparing approaches or varied flap approaches using perforator flaps, we continue to improve what we do.

I think one of the other things that we're seeing is that women are coming in for their consultation better prepared than ever before. Much of that is due to improvements in online educational and community support resources as well as ASPS initiatives like Breast Reconstruction Awareness Day. As I mentioned earlier, patients now frequently see a plastic surgeon first before even meeting with a breast surgeon. There's been an evolution that the role of the plastic surgeon early on in the decision-making process has become critical.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.


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