What is a breast?

What is a breast?

Now don’t look at me as if I’m mad. It’s a valid question, and one that I thought I knew the answer to.

I’ve spent three of my final 6 years training as a surgeon focusing purely on breast surgery, learning how to treat breast disease, from harmless to serious, and how to operate, reshape and reconstruct a breast and a nipple.

During my final year of training and my first year as a consultant, I studied towards an MSc in Oncoplastic Breast Surgery. Oncoplastic is a fancy word for what is now the norm when it comes to removing breast cancer and pre-cancer. The vast majority of surgeons in the UK are now trained in plastic surgical techniques to hide the scars, reshape and recreate a breast mound, reduce, re-size and reconstruct breasts and nipples. We do what we can to give women a good cosmetic outcome,whilst our main focus is good outcome from the cancer operation.

During those two years, I literally read over a thousand scientific papers and journals. I studied in depth the anatomy, physiology, embryology, microbiology and endocrinology of the breast. I studied the mechanisms for all the various diseases that can occur, and reviewed hundreds of clinical trials covering every aspect of breast cancer treatment, including medicine (with tablets), surgery, radiotherapy, chemotherapy and palliation.

A breast is an unusual part of the body. Simply, it’s just mound of fat and connective tissue covered by skin, with a nipple attached. But it’s so much more than that. It can produce milk to feed a baby. It’s an erogenous zone. It can cause severe pain. And every breast is different. There is no such thing as a typical breast, and they can change dramatically over a woman’s lifetime. Some are perky, some are saggy, they can weigh anything from 100g to 1.5kg, and nobody has an identical pair. I tell all my patients that their breasts are sisters, not twins, so when I operate, I’m not promising symmetry and perfection, I’m trying to recreate what they already have.

And then there is the social / cultural aspect. Do you show your breasts in public or keep them covered up? You maybe go topless in Spain but never in the UK. You might flaunt your cleavage in a nightclub but hide it in church. Breasts have an identity of their own - mainly sexual in the media. Topless celebrity photos sell magazines and newspapers. Not just a mound of fat, then…

I’ve never given my own breasts much thought as an adult. I’m fortunate in that they’re in proportion with my shape, I don’t have to spend a fortune on expensive bras for the larger cup-sized women. And by the way, I know they’re more complicated to make, but why are they so much more expensive? It’s not a woman’s fault that she’s an H cup - why make her pay double or triple for her bra? Rant over. Back to me. I can run for a bus without holding on to them, and they’ve never given me cause for concern. Until now.

Suddenly I’m facing the prospect of losing a breast. What an odd choice of word. It makes me think that I’m careless, and misplaced it like those things you put in safe places but can never find.. But what word do you use instead of a mastectomy? The surgical term is a harsh one, and most of us will automatically conjure up an image of an ugly scar across a flat chest. That is so far from reality, as every woman who needs a mastectomy is now (or should be) offered a reconstruction, and we can do amazing things. Nipple-sparing mastectomies are becoming more common in smaller cup-sized women, and with a scar hidden in the bra-line, it can be hard to tell you’ve had surgery.

But I digress. The breast is going to go. And I’ve had to start thinking about how I will feel, and do I want a reconstruction? It reminds me of a line in a song but I’ve no idea who sang it or what the title was - You don’t know what you’ve got til it’s gone… (My amazing husband has told me that it’s Joni Mitchell’s Big Yellow Taxi).

I need to work out how my breast relates to me - my identity, my sexuality, my image. Will I still feel like a woman? Can one breast compensate for two? Do I actually need or want a reconstruction? How important is my active lifestyle in that choice? Will I ever accept what I see in the mirror? Will my husband? Do I need to grieve for the breast-feeding that will never happen? If I do have a reconstruction, do I want to keep my nipple? Again - how attached am I to it? How does my nipple define my breast? If I keep it, it won’t ‘work’ as the nerves will have been detached, so it will be numb. Do I need to see a nipple in the mirror to help me accept my reconstruction? Would a tattoo or a reconstructed nipple do the job?

I’ve had the agony and the luxury of 5 months’ of chemotherapy to think about all of this, and I’ll write another blog about the surgical decision making and the stresses (self-imposed and external) that it caused. But it’s made me think about how I practice breast surgery.

As a breast unit, we get financially penalised if we bring women back to clinic too many times, so I routinely see a woman once after her biopsy. In this allotted 10 minute consultation (which for cancer normally takes 15-60 minutes, so we always run late), I often have to do the following:-

- tell her she has cancer
- tell her she needs a mastectomy
- tell her the risks of needing chemotherapy or radiotherapy afterwards
- as if she would like a reconstruction
- talk through all the reconstruction options and the pros / cons
- tell her whether she is able to keep her nipple or not

As you can imagine, this is a hell of a lot to take on board, but I have to cover it in that one appointment. And the woman probably takes in a fraction of what I say about complex surgical decision making, because she’s still dealing with the fact that she has cancer. The breast care nurses are wonderful, and sit with the patients after I’ve left the room, and we give them lots of information leaflets. For those women who want a reconstruction, we’ll plan to see them in a week’s time once they’ve made their decision. But that gives them only a week to come to terms with how they feel about their breasts. I’ve been struggling and I’ve had months to mull it over.

No-one can imagine how they will feel about their breasts until they’re told one needs to be removed, and any decision a patient makes is as a cancer patient, not as a healthy woman. Your priorities and motives are naturally skewed. Often my patients decide to have a quick implant reconstruction instead of a complex one using tummy fat (which would make a more natural feeling and looking breast), so they can get back to looking after their toddlers at home, or to go flat so they can quickly start life-saving chemotherapy, and worry about their appearance once they’ve finished treatment. Some come back to have revisional surgery and get the reconstruction they initially wanted, but many don’t. I never know if they regret their decision. You can only make the decision that is right for you at the time, but it’s clear to me now that a breast is not just a mound of fat.










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