“I’m having a mastectomy, can I expect my breasts to ever look the same?” — Terry, Toronto
What a huge and important subject, Terry. First of all, I’m so sorry you are going through this. This is a subject we just don’t talk enough about. Even if it hasn’t happened to us personally, I’d venture there are vanishingly few among us whose lives have not been touched by breast cancer, as so many of us have wondered how to help family and friends, and to understand what is going on for them.
We are so very lucky this week to have access to the expertise of Dr. Toni Zhong, a plastic and reconstructive surgeon at University Health Network. She is also an associate professor in the Department of Surgery at the University of Toronto and the inaugural Belinda Stronach chair in breast cancer reconstructive surgery. I’m grateful she could take the time to talk us through the complicated and ever changing landscape of reconstruction choices faced by women undergoing a breast cancer diagnosis.
Zhong emphasizes everyone’s journey is different around mastectomy and reconstruction conversations and decisions. Some patients, she says, have different options based on their particular situation. “Every hospital,” she adds, “is a bit different in timelines and procedures.” She says there are two different stages at which she first meets her reconstruction patients. Sometimes she is brought in shortly after diagnosis, once the patient’s care team has done “the workup, the mammogram, the ultrasound imaging, the biopsy.” Sometimes she meets her patients later on in the process.
A general surgeon will remove the breast or do the lumpectomy. Some patients, Zhong says, are good candidates for breast reconstruction at the same time. Others may require the reconstruction to be delayed. Yet other patients choose to do no reconstruction at all.
The challenge for a reconstruction surgeon “is matching a natural pair of breasts” if the patient wants to keep the bra size they have. But, says Zhong, “about 50 per cent of women want something different, something larger or smaller” than their current cup size. If you want to change the breast that is not affected by cancer — larger or smaller — she says, “I like to delay the alteration to the other side until later, because cancer surgery can be quite lengthy.” It also gives a chance for swelling to go down after healing, for a better match. Zhong describes her surgical style as conservative, adding that doing the process in stages can lead to better outcomes. “It can take months after healing for breast shape and size to settle in.”
Zhong’s husband is Dr. Brett Beber, also a plastic surgeon. Beber does breast surgeries as well, chiefly for cosmetic reasons. Zhong points out that there is an intersection between cancer reconstruction surgery and breast reduction/enhancement surgery for cosmetic reasons. “The patient has the same esthetic expectation,” she says, “whether they have had breast cancer or not.”
As a reconstruction surgeon, Zhong says, “you develop a relationship with the patient, and how the final result looks is very important.” She was named the Belinda Stronach chair in 2017. Stronach, she says, “had to go to California when she was diagnosed with cancer many years ago, because at the time immediate breast reconstruction at the same time as mastectomy was still not the norm in Canada.” So Stronach endowed a chair to make that option, and other innovations, a reality here.
To get to the esthetic nitty gritty: “You can sometimes save the nipple,” she says. “A lot of innovations have been done and in many cases saving the nipple is safe when the tumour doesn’t involve the ducts that drain into the nipple, and if (the cancer) is far enough away and not aggressive enough.”
This is something Zhong calls “a real game changer for patients. Not only is the nipple a very central landmark for the breast, but in the past when we had to remove (the nipple), the scar is located right in the middle of the breast at the centre of the breast mound over the most visible part of the breast.” Nipple removal, she says, can “leave the breast mound flat and boxy.”
Augmentation surgery has changed over time, too, according to Zhong. “A lot about what kind of implants are safe and their compositions have changed, and surgeons utilize different muscle planes to place augmentation to make it more natural. These smaller technical nuances make a big difference,” she says.
As for improvements in reductions, she says, “There are different incisions we can make for breast reductions, as well as where tissue resection should come from.” Liposuction to contour the lateral sides of the breast can make the shape a lot more esthetically pleasing.
If you do go for implants, says Zhong, “everyone is different and has different preferences. After reconstruction, because the breast tissue is all gone (in a full mastectomy), you are looking at skin with little fat. So silicone is much more natural feeling and looking. Saline is like a water balloon and it feels like saline.”
If the patient prefers to use her own tissue, there are innovative solutions now for that, too. “Some patients are naturally a bit droopy on the other side. I would probably advise her to use her own tissue for reconstruction. Her own abdominal skin and fat for building the breast can be shaped to match other side.” This is, however, a much lengthier surgery, with more recovery time, she says.
I went technical in this answer, Terry, because I believe it is a privileged opportunity to get a surgeon like Zhong to explain all the different scenarios. What is unsaid is what Zhong talks about when she talks about the relationship between a surgeon and a patient, for cosmetic or reconstructions reasons alike. Changes to your body are fundamentally hard and take a lot of talking through to achieve the best results for you. The issue involves the mental and emotional side of treatment.
The good news is that when the worst happens, medical innovation — and surgical art — is making it much more possible for your breasts to look as close to the same, or different but still matched as you desire.
To all the rest of us who are reading this to support our loved ones through a difficult time, let’s keep raising money for breast cancer initiatives like the Stronach chair. And if you have breasts yourself, do check them out on the regular and get a mammogram as soon as, and as often as, your doctor tells you to, please.
Shop the advice: Mastectomy-specific undergarments and swimwear, and a sleepwear that helps with night sweats
Lusomé nightshirt, $110, lusome.com SHOP HERE
Elegant and cosy, suitable for lounging. Patented, proprietary Xirotex fabric draws perspiration away from the skin swiftly and accelerates evaporation so night sweats (a common side effect from hormonal changes, chemotherapy and other medications) won’t keep you awake.
La Vie en Rose mastectomy bra, $59, lavieenrose.com SHOP HERE
Full-coverage cups with underwire that stops low on sides for comfort, limited cleavage covers radiation tattoo, four levels of adjustment. And very pretty indeed.
Body by Victoria mastectomy bra, $67, victoriassecret.com SHOP HERE
This soft and comfortable mastectomy bra is unlined and wireless, with pockets for prosthetic inserts. Partially recycled lace adds a nice touch.
Lands’ End mastectomy swimsuit, $53 (on sale from $147), landsend.com SHOP HERE
Long-lasting, chlorine-resistance Spandex with a flattering square neckline and ruched detailing on bodice below the bust. Soft cups to fit prosthetics.
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