“Ten hours? For breasts?”
During my career, I've been in countless hospital hallways and operating-room lounges where a colleague glances at the surgery schedule. A breast reconstruction using a woman’s own tissue is booked for most of the day — and he asks some version of that question. It reflects an attitude I’ve encountered throughout my career: that rebuilding a woman’s breasts after cancer is a nice extra, the part you do once the real medicine is over.
Often, these comments come from doctors who don’t treat breast cancer patients. "Why is she on her third revision?" "They’re just breasts." What bothers me most is that my patients seem to have absorbed the same message, even when nobody says it to their faces. Many of them walk into my office already apologizing. But the operation is complex, involving moving tissue from a woman's abdomen to her chest, and reconnecting blood vessels a couple of millimeters wide under a microscope.
I’m a man. I will never know this particular loss from the inside. I know it from the other side of the exam table, where women tell me things they say they haven’t shared with their partners.
“I know this is probably vain,” a patient might say, before asking me to fix an asymmetry after her third surgery. Her family tells her the important thing is that she’s alive, and they’re right. October hands her a pink ribbon and a "keep on fighting" slogan. Somewhere in all that, her grief gets filed under vanity, and medicine has been doing the filing for a long time.
My profession spent most of the last century deciding what women’s breasts were worth, usually without asking the women.
Until the 1970s, a woman with a suspicious lump was often put under anesthesia for a biopsy. If it came back as cancer, the surgeon performed a radical mastectomy on the spot, taking the breast along with the underlying chest muscles and lymph nodes under the arm. She went to sleep not knowing whether she would wake up with her breast. The one-step procedure left her no chance to discuss the diagnosis and her treatment options between the biopsy and the mastectomy.
One of the people who pushed back was a journalist named Rose Kushner. After finding a lump in 1974, she refused the one-step procedure and was turned down by surgeon after surgeon before one agreed to do only the biopsy. She spent the rest of the decade fighting the surgical establishment, until a 1979 National Institutes of Health panel recommended separating the biopsy from the decision to operate.
The habit of making decisions without women’s input outlasted the one-step procedure. In 1998, Congress passed a law requiring most health plans that cover mastectomy to also cover reconstruction. Yet a University of Michigan study published online in 2007 found that only a third of 1,844 breast cancer patients surveyed in the Detroit and Los Angeles areas reported discussing reconstruction with their general surgeon during treatment decision-making.
My own corner of medicine has its version. In 2024, women accounted for just 19 percent of the American Society of Plastic Surgeons’ U.S. membership. For decades, men dominated decisions about what women’s breasts should look like. Women who had augmentations in the 1990s and 2000s have told me they asked for a C cup and woke up much larger, because someone else decided they’d look better that way. Their own opinion came last.
So when a patient apologizes for what she misses, I wonder how much of that history she’s absorbed. After a century of other people deciding what her breasts were worth, it sounds like someone who learned to dismiss them before anyone else could.
The profession itself is starting to change. A 2024 report from the society put women at close to half of residents entering the specialty. But none of us should wait for a more representative profession to start asking patients what they want.
I’m critical of beauty ideals, but I understand wanting to look in the mirror and recognize yourself. When my patients talk about what they miss, they describe the body they recognized in the shower for 30 years, and the parts of it they liked.
Some of them tell me they miss feeling desirable. They tell me last, usually with an apology attached, as if wanting to feel wanted were something to confess in the middle of cancer treatment. Partners may stay quiet too, afraid even asking will sound selfish. So the loss can go unspoken in a relationship.
Even the best reconstruction leaves her without the breasts she had. The nipple may also be removed, though nipple-sparing surgery is an option for some women. Mastectomy cuts nerves, causing numbness and loss of feeling whether a woman has reconstruction or goes flat. Some sensation may return over time, and surgeons are developing techniques to preserve or restore it, but it may not return to what it was. Some patients tell me their new breasts look right in clothes but feel like someone else’s in bed.
Plenty of women choose to go flat from the start, and others choose it later, after reconstruction hasn't worked for them. That choice deserves the same respect, and women who make it may grieve too. Some women have reported that surgeons left extra skin in case they changed their minds about reconstruction, despite their wish to go flat. That's another decision made without her consent.
Then there are the women who never had cancer at all. Women with harmful variants in the BRCA1 or BRCA2 genes, and some others at high inherited risk, may choose to have healthy breasts removed to reduce their cancer risk. They’re told they’re lucky. Some are also grieving body parts that never did anything wrong. In this culture, breasts get to be two things at once: a measure of femininity and a risk to be watched. Women carry both, and October mostly talks about the risk.
In my office, I tell her she can be grateful to be alive and still grieve what it cost her, whether her cancer is behind her or something she’ll live with. Nobody gets to grade her loss by how serious her cancer was. Some women feel relief, or very little at all, and that deserves the same respect. Whatever she feels should be hers to name.
If you love someone going through this, stop telling her it’s just breasts, and let her say she misses them without rushing to remind her what she gained. If she says she feels less attractive, listen to how she feels before you rush to reassure her.
Breast Reconstruction Awareness Day, observed this year on October 21, promotes awareness of reconstruction options. When a woman apologizes to me for what she misses, I tell her she doesn’t owe me an apology — and she doesn’t owe one to the doctor in the hallway, either. Whatever he thinks, they were never just breasts.
Sean Saadat, MD, is a board-certified plastic and reconstructive surgeon in private practice in Beverly Hills, California. He trained in plastic surgery at UCLA, where he was chief resident. He has no financial relationships with implant, reconstruction, or nerve-repair companies and no role with the Breast Reconstruction Awareness campaign.
