Breast Reconstruction: Why Patient Perceptions Differ

By Constance M. Chen, MD, MPH

Breast reconstruction after mastectomy is a very subjective experience. Different women who undergo the same type of breast reconstruction may have very different perceptions of newly reconstructed breasts depending on the starting point. In general, the best result in breast reconstruction today is achieved with natural tissue, in which the patient’s own body, usually the abdomen or legs, is used to create a new breast that replaces the fat and skin that was lost to mastectomy. Since it is made from the patient’s own tissue, the restored breast is soft, warm, and reacts just like any other part of the woman’s body, growing or shrinking as weight is gained or lost, for example.

The newest advance in breast reconstruction is the use of microsurgical techniques to reconnect nerves and restore feeling to the breast. During a mastectomy, the nerves that provide feeling to the breast and nipple are severed, causing loss of sensation in the remaining skin whether the woman undergoes reconstruction or not. Now, with natural tissue breast reconstruction, nerves can be transferred along with a woman’s own tissue to form the new breast and they can be reconnected to blood vessels, making it possible for the nerves to grow through the tissue to reach the skin and significantly improve the return of sensation. While results vary, this technique can provide some women with restored sensation.

Even if a woman undergoes natural tissue breast reconstruction with sensory restoration, however, the “gold standard” of breast reconstruction, the degree of her satisfaction is often influenced by the history of her breasts. Women undergo breast reconstruction at different stages and for different reasons, and those differences create differing perceptions of the outcome. For example, some women have immediate reconstruction – at the same time as the mastectomy. Some women have breast reconstruction after unsatisfactory implants. And others have delayed reconstruction – months or even years after the mastectomy. These women may all have the same state-of-the-art surgical procedures, yet each will have a different basis for comparison and a different perception of her reconstructed breast.

We have made remarkable advances in the surgical techniques that can create a soft, warm, natural-looking breast. A woman’s perception of her reconstructed breast is often influenced significantly by where she is starting from, however. Even if her breasts look and feel normal to people around her – her partner, her family and friends – to the woman herself, it may not look or feel at all like the natural breast she lost.

The same surgical procedures may produce different perceptions of success

To the outside world, the absolute best outcome usually comes after a nipple-sparing mastectomy and immediate natural tissue breast reconstruction with nerve grafts. In this situation, the woman preserves all of her outer breast skin and nipple-areola complex, and the new breast is filled with soft, warm tissue and reconnected nerves that may restore feeling to her breast. It may be very difficult for other physicians or even a patient’s partner to tell that the patient has undergone a mastectomy, because her breasts look and feel normal. Yet a woman who has gone from a completely normal breast to a reconstructed breast may actually experience the most shock and trauma after acutely losing a normal breast. Her body has changed, and patients sometimes cannot get over the appearance of new scars at the donor site – even if they are well-hidden. Despite the fact that she has a state-of-the-art breast reconstruction, the patient may feel intensely depressed from the loss of her old breasts that she has lived with for her entire life.

In contrast, a woman who has undergone implant-based breast reconstruction, and then has her implants removed and replaced with natural tissue breast reconstruction with nerve grafts, is often overjoyed with a natural tissue breast reconstruction – even if she has a surgically reconstructed nipple or no nipple at all. The contrast between hard, cold, and artificial breasts that are tight, painful, and immobile underneath the pectoralis muscle and soft, warm breasts that jiggle and feel natural in the space above the pectoralis muscle in the space where her breast tissue used to be often leads to comments that the new natural tissue breast reconstruction “feels like my breasts did before my mastectomy.

The women who delays reconstruction for months or years is also likely to be quite happy with her reconstructed breasts after “going flat” or using prostheses. While the aesthetic result of reconstructed breasts after previous implants or no reconstruction may not be as good as that of the woman who had immediate reconstruction with a nipple-sparing mastectomy, patients who are comparing her new natural breasts to painful implants or a flat chest wall are often extremely happy after experiencing the downfalls of uncomfortable implants or a flat chest. A woman’s starting point often shapes her reaction and her satisfaction with the reconstruction.

A woman’s perception of her restored breast is her reality. As medical professionals, we must treat the whole woman to help guide her through both the physical and emotional aspects of surgery.

Constance M. Chen, MD, is a board-certified plastic surgeon with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine. She is also Chief of Microsurgery at New York Eye and Ear Infirmary of Mount Sinai. www.constancechenmd.com