A local reporter called me to discuss Jolie’s drastic action; when our conversation shifted to breast reconstruction, the reporter asked, “Well of course Jolie had reconstruction, what woman wouldn’t?” This question might seem to be logical (and a foregone conclusion) to those who are unfamiliar or untouched by mastectomy. We routinely replace worn-out hips, out-of-whack knees and other faulty body parts; why then, wouldn’t it also be a no-brainer for women to opt for reconstruction after losing such an intensely private and personal part of themselves?
While many women consider breast reconstruction to be an option that they can do without, each year tens of thousands of women who lose their breasts to either treat or prevent cancer have post-mastectomy reconstruction. For high-risk women like Jolie, the possibility of returning to a near-normal (or improved) natural feminine profile eases the very difficult decision to have preemptive mastectomy. As one woman explained reconstruction to her child, “It replaces the stuffing in Mommy’s breast.” That might be a bit simplified, but it’s accurate: reconstruction doesn’t restore sensation or the ability to breastfeed, but it does replace breast tissue that is removed during mastectomy with implants and/or a woman’s own excess fatty tissue from elsewhere on her body.
Jolie made informed and carefully considered decisions that were right for her, but they are not the only options, and other women, even those with a similar level of risk might prefer a different path.
- Genetic counseling and testing. Based on her family medical history, Jolie consulted with a genetic counselor, who determined that she was indeed a candidate for genetic testing; results showed that Jolie has an inherited mutation in the BRCA1 gene, which greatly elevates the likelihood of developing breast, ovarian and other cancers.
- Preventive bilateral mastectomy. Prophylactic bilateral mastectomy is the most effective way to reduce hereditary risk, but some women who have a BRCA gene mutation prefer to take medication (tamoxifen) to reduce the risk of breast cancer or increase surveillance to detect any breast cancer at an early stage when the odds of successful treatment are increased. Jolie also opted for nipple-sparing mastectomy, which is considered to be quite safe when included as part of preventive mastectomy (during the mastectomy procedure, a small tissue sample from beneath the nipple is tested by a pathologist; if cancer cells are found, the nipple is removed). The good news is that women who keep their nipples retain a small part of their natural breasts, and preserve the natural projection of the breast after reconstruction. The not-so-good news is that sensation is usually decreased, changed or sometimes eliminated after nipple-sparing surgery.
- Immediate reconstruction with tissue expanders. Although all plastic surgeons don’t perform all reconstructive breast procedures, breast tissue can be replaced by implants, a woman’s own tissue, or a combination of both. Jolie chose the most common method of reconstruction: tissue expanders that gradually stretch muscle and skin to make room for implants. Her expansion was completed in just nine weeks: a process that most physicians prefer to complete over a period of several months. A newer method offered by some surgeons places implants immediately, altogether eliminating the need for expansion.
With her double mastectomy and reconstruction now behind her, Jolie, who has been called “the most beautiful woman in the world” wrote, “…I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity.” She certainly didn’t have to go public with her story. (Arguably the priority of many in her profession would have been to remain quiet on this intensely personal issue.) By sharing her experience, Jolie opened dialogue about the power of individual choice, while encouraging women to make their own informed decisions.