“The implant felt alien immediately,” says Claudia Manchanda, who had a single mastectomy after her breast cancer diagnosis in 2013 aged 42. “My new ‘breast’ was pert and looked fake. It felt like I had a piece of plastic shoved under my pectoral muscle. It never made me feel better or ‘normal’.” Had she felt there was a choice, she would have chosen not to have reconstruction and simply be ‘flat’ on one side. This was not an option that anybody mentioned.
“I was told by the oncoplastic surgeon that, since I was a young woman, immediate reconstruction would help me move on with my life,” she explains. But six years later, after a year of asking, she finally had the implant removed. “I fought for it,” says Claudia. “I had to see a psychiatrist. There was immense pressure to keep it.”
It’s difficult to stand your ground in the face of medical professionals insisting what will make you feel “normal”, particularly when you have a cancer diagnosis so are already scared and vulnerable. “Breasts are very sexualised,” Claudia continues. “They even ask, ‘What would your partner like?’ It’s bizarre. I’m sure that men having orchidectomies for testicular cancer aren’t asked, ‘What would your partner prefer?’”
You might imagine that the issue is partly male surgeons not acknowledging that some women would prefer to go flat. “But my whole team were women,” says Claudia. “Women uphold patriarchy too. There was too much focus on aesthetics over survival for my liking. Too much pressure to be symmetrical and, to quote my surgeon, be ‘beach ready’.”
Adjusting to having one breast took a few weeks, since asymmetry is not visible in society. “Everyone deserves choice,” she says now. “We need to see images of flatness, as well as reconstruction.” On a mission to improve this visibility, Claudia has modelled for Uno, a brand that makes beautiful one-cup lingerie and swimwear for asymmetric bodies (unobra.co.uk).
“[Surgeons] talk to women about how they can feel ‘normal’ again after cancer but what they mean is ‘normal’ in the eyes of others,” says Katy Marks, who founded Uno after her own experience of mastectomy without reconstruction. “It’s astounding that this affects so many women but our real bodies are kept invisible by the fashion choices on offer and by societal pressure that this is something to hide. We need to see representation of asymmetry and understand that beauty is diverse.”
Your surgical options after a mastectomy will depend on many factors, but the choice to go flat should be one of them. If you would like reconstruction, but hate the idea of an implant, there are alternatives.
Georgette Oni is an oncoplastic breast surgeon at the Nottingham Breast Institute. “In terms of reconstruction, your options are either using a foreign body, which is an implant,” she explains. “Or using your own body, which is called autologous reconstruction.”
The best-known type of autologous reconstruction is DIEP flap, where the new breast is moulded out of fat from another part of your body, usually the abdomen. Both options have pros and cons, although most people still have implants.
“A lot of patients will choose implants because they want a quicker recovery, which you get because you’re not taking bits from other parts of the body,” says Miss Oni. “But the trouble with an implant is that your body knows it’s a foreign body, so it creates a wall around it called a capsule. With time, that capsule can become tight and change the shape and feel of the breasts. The other thing is that there can be issues with implants that mean requiring other operations over the course of your lifetime.”
If you decide not to have reconstruction, this is known as ‘aesthetic flat closure’. “There will be scarring,” says Miss Oni. “But, with the latest techniques, we try to make that scar sit as flat and as low as we can, because that helps with overall aesthetics.”
When Camilla Young, 40, was diagnosed with breast cancer three years ago, she was told she’d need a double mastectomy since she had the BRCA gene mutation.
“I said initially that I didn’t want reconstruction,” she remembers. “Both my oncologist and plastic surgeon said, ‘No, you’re so young.’ It didn’t seem like going flat was an option, but I didn’t like the idea of fake boobs, so I was leaning towards DIEP flap at first.”
DIEP flap is major surgery, requiring 8-12 hours under anaesthetic and a long recovery period. This was never fully explained to Camilla.
“Then I spoke to someone who’d had it, and she told me she couldn’t do anything for three months,” she says. “At the time, I had an 18-month-old child, so I realised that was going to be impossible.”
Having reluctantly agreed to implants, there was still a lack of choice. “I knew that, if I was going to have implants, I wanted them to be smaller,” she says. “But they insisted it was best to replicate what I had. I said: ‘Please. I don’t want reconstruction but, if I’m going to have it, can they be small.’ They brushed me away with a ‘let’s see’. They didn’t listen.”
After surgery, Camilla was dismayed to find that the surgeon had given her large implants to mimic her previous breast size. Not only that but, within a month, one of them became infected and she was back in hospital for further surgery to remove one of the implants. Having chosen not to have DIEP to minimise time away from her child, she was now trapped in hospital for two weeks – during the pandemic, when no visitors were allowed.
“Then I was lopsided for a few months, during which they kept saying they could replace the implant,” says Camilla. “And I was like, no way! Please take the other one out. I just want to be done with this.” Heartbreakingly, she adds: “I partly blame myself. I wasn’t vocal enough, and I should have pushed harder. But at the same time, I felt so vulnerable, and I was on my own for every appointment because of Covid restrictions.” Knowing what she knows now, she would have done things differently. “I would have put my foot down and said, ‘I’m not having reconstruction. Just take them off,’” she says firmly.
Miss Oni tells me that a breast surgeon’s priority should be not only their patient’s survival, but also their ability to live well afterwards. “If every time they take their clothes off, they are confronted with a terrible-looking scar or a really poor reconstruction, it will have a very long-lasting effect on their psyche,” she says. “We are always working on new techniques for making sure that the reconstruction or closure is as pleasant on the eye as possible, because it will be looked at on a daily basis by that patient.”
Being clear about every option could avoid unnecessary surgery for breast cancer patients and the accompanying pain, scars, stress and time away from their families.
“The options should have been laid out: DIEP flap, implants, or going flat,” says Camilla. “Going flat was never an option presented to me. It was my suggestion. But it would have been really helpful if they had brought it up. Then I could have seen it as a viable option, rather than just my crazy idea.”
Reconstruction: How to Rebuild Your Body, Mind and Life After a Breast Cancer Diagnosis by Rosamund Dean is out now
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