Three women on why they said no to breast reconstruction after mastectomy
Tanya Dobbyn sought a double mastectomy without reconstruction. ‘I didn’t and still don’t feel I need breasts to be womanly or sexy,’ she says.
Diagnosed with breast cancer at just 24 — and then finding out she has the BRCA1 gene mutation — Tanya Dobbyn was in no doubt about what she wanted. She wanted a double mastectomy — and she did not want breast reconstruction.
“I’d made peace with my body. I didn’t, and still don’t feel I need breasts to be womanly or sexy or feminine.”
Now 32, Waterford-based Dobbyn says her decision to go flat took into account the “risks of surgery” and that reconstruction could involve multiple surgeries. “One option would have been implants put in straightaway following mastectomy. I didn’t want to go through that. I chatted with women in Facebook groups and — yes — for some, implants had turned out lovely. But others weren’t happy — their desired look hadn’t been achievable.
“Some women had implants removed. I didn’t want to go down that long process. I was happy just to remove my breasts and get on with life.”
We have no national figures in Ireland for women who opt for breast reconstruction and who don’t. US data gathered in 2022 shows 43% of women there receive reconstruction after mastectomy. An Irish Examiner query to the Hospital Inpatient Enquiry (HIPE) department shows 595 discharges from acute hospitals for breast reconstruction in 2022, and 638 in 2023. The data relates to all women who had breast reconstruction, not just following mastectomy, and it ‘may include multiple admissions for the same patient’.
Most women undergoing reconstruction are under 60. For example, in 2023, there were five times more women in this category than in the over-60 age range.
Carol Spillane, cancer nurse with the Irish Cancer Society, spent 13 years as a clinical nurse specialist in breast cancer at St James’s Hospital. She finds women are opting for reconstruction more frequently than before. “But it’s still not as common as people think.”
Women do not opt for reconstruction to cover up scars, says Spillane – or because they want an ‘upgrade’. “They will have scars after reconstruction, though the scars will be very dependent on the type of reconstruction. And it’s not to improve on what they had, because breast reconstruction is very different to breast augmentation – following mastectomy all of the breast is gone. So it’s forever different.”
The major reason why women opt for reconstruction is simple: they don’t want to wake up without a breast. “They want it for body image reasons, to restore their confidence and for emotional healing.”
Pointing out that body image is “a very complex construct that spans a person’s self-perception and beliefs, their emotions and behaviours related to physical appearance and their body’s functions”, Spillane says mastectomy permanently alters all of those, so body image takes a huge knock. “Mastectomy alters the appearance and sensations of her breast, the woman’s feelings about herself and the functions of her breast, particularly for younger women when the breastfeeding option is removed.
“In the western world, breasts represent femininity. A big thing women say is ‘I don’t feel like a woman anymore’. It affects relationships. It’s common to hear ‘I can’t look at myself — how can I let someone else look at me?’ When a woman loses her breasts, there’s a grieving process. She needs to adapt to a new body image.”
Dr Reem Salman is a consultant breast surgeon based in The Beacon and Beaumont hospitals who offers breast reconstruction. Whether to opt for the procedure or to stay flat, she says, is ultimately a very personal decision. “Mastectomy creates a defect — you’re removing an organ. It’s a very critical decision for the woman whether she accepts to live with it, or does she want to reconstruct it?”
Salman says women make this decision based on multiple factors. “How confident is she with her body shape? What is the psychological, emotional, physical and social impact of the surgery on her? Is she accepting of going flat on one side? How does she feel about sexual attraction? Some women say I’m just glad the cancer is gone.”
She finds most women she sees want to discuss reconstruction after mastectomy – and says all the ramifications of the ‘to have or have not’ decision needs to be explored with a woman facing mastectomy. “Sixty per cent of women I meet want to go ahead with reconstruction immediately.”
There is always a personal decision behind a woman’s decision. Salman recalls one woman wanting immediate reconstruction because she ran a business as a swimming instructor. “She said, ‘I can’t go flat on one side’. Some women want reconstruction to ‘regain’ their femininity — for others it’s for symmetry and shape rather than femininity.”
While Spillane says immediate reconstruction gives a better outcome – “there’s less scarring on the breast, whereas with delayed you need to take tissue from somewhere else so it’s a two-part procedure” — she points out that there is still a case for delaying reconstruction. Smokers or those with co-morbidities like diabetes or obesity are at increased risk of complications with immediate reconstruction.
“Also, if a woman has a tumour requiring radiation, we recommend delaying reconstruction — wound infection, for example, could delay cancer treatment. And, of course, sometimes it’s the patient’s choice to delay because they’re not sure about reconstruction.”
In Spillane’s experience, women decide against reconstruction because they want to get through treatment without any additional procedure or risk factor. “Essentially, they want to move on, have a speedier recovery. Regardless of what type of reconstruction, it’s going to be a large operation. If it’s implant-based, it could add two hours. If it’s autologous flap reconstruction, it could add four to six hours. You’re adding all that extra time under anaesthetic.
“And while risk factors associated with reconstruction are low, they do exist. With the flap-type, a woman has a breast wound as well as somewhere else — fat tissue is taken from the abdomen, meaning a scar from hip to hip. More time in hospital, a longer recovery period, more risk of complications, and the likelihood of more surgeries for symmetry — women take all these into consideration,” says Spillane.
It all adds up to a lot to think about, and Salman points out that women are making these almost “overwhelming” decisions at a time when they have just discovered they have breast cancer and are grappling with concerns about treatment, prognosis and survival. She has met women who opt to go flat for economic and parental reasons. “They’ve a young family and they can’t take more time off work, or there’s nobody to mind the children at home and they look for faster recovery from the cancer surgery. Some people are just happy to be alive after this diagnosis — they’ll say ‘it doesn’t bother me how I look’.
Both experts are adamant that pre-op education is vital. Salman makes women aware of the surgical options, including that of ‘no reconstruction’, via pictures. “If a woman wants to stay flat, I show her a picture of a mastectomy scar and provide her with the option of delayed construction if she wishes to consider at a later stage.”
Spillane also educates using photos — women are “always taken aback and shocked” when they see these. “It’s a big change, to have a breast and then not”. But after the initial shock, they are glad to have seen them. “They say it helps them prepare for what they’ll look like after the surgery.”
Celbridge-based Colette Mullen, 56, was diagnosed with a “quite aggressive” cancer in her left breast in 2022. From day one, she wanted a double mastectomy, largely because of family history — two of her sisters had breast cancer. “I was worried the cancer would come back in the other breast. I’d always said I wouldn’t have breast reconstruction — my consultant said, ‘I can see you’re adamant about it’.
“I was always big-chested. It was a problem — nothing ever fitted me. I felt reconstruction would involve a lot of pain, surgery, and I worried about infection. My sister had reconstruction when she was 34 and got a terrible infection. I also didn’t know how reconstruction would look.”
Mullen doesn’t think she would have decided differently had she been younger. “Patrick, my husband, is fine about it. He always said it was whatever I felt comfortable with. I don’t feel less of a woman. For me, two breasts do not determine a woman.”
Alice O’Brien, 65, had always said, “I’ll be going for mastectomy if it happens again”. O’Brien meant breast cancer — she had first been diagnosed with a very aggressive type, aged 48. This was 2008, and she underwent a single mastectomy.
When she was diagnosed this May with early stage cancer in a tiny area of her remaining breast, she was offered lumpectomy — medics said this would be very simple. “I said ‘no it won’t’ — I had my mind made up [about getting a mastectomy].”
Breast reconstruction never appealed to the Waterford-based mum-of-three. “I feel if cancer comes back in a year or two you wouldn’t know. I don’t like the idea of hiding something that could develop under [the reconstruction] that could get out of hand,” says O’Brien, who breastfed and believes “that was the design for breasts — they’ve become totally sexualised.”
She understands women opting for reconstruction. “I just have a different way of thinking about it all.”
Dobbyn, who met her boyfriend post-mastectomy, post-decision-to-go-flat, told him about it on an early date. “He was very understanding. I didn’t feel I had to overly explain it.” But seven years on, she is still asked by some when she will be going for reconstruction. “They don’t understand this is my final decision and I’m happy with it.” And while she doesn’t feel medics ever tried to talk her out of her decision, she does feel she needed to “really argue” for her ‘going flat’ choice.
In 2021, research published by the found that almost 75% of women who chose to forego reconstruction were satisfied with the results. For Dobbyn it is simple: “I just wish the world was more accepting that there are women out there with two, one or no boobs.”
O’Brien feels more natural, having no breasts, than she did when she had one. But no matter what, she is proud of her body. “I have lots of scars and I’m very proud of my body because I have a good body. People should just love their body.”
- See: cancer.ie
