There was a time when Rhonda Williams loved her breasts — round, perky C cups that looked especially great in the tight, body-contouring dresses she often wore. “I think about them all the time,” she told me. When she does, she remembers how confident they made her feel, and the pleasure of another person playing with them — especially with her nipples. It was once her biggest turn-on. When she searches for a word to describe the breasts she used to have, “fantastic” is the one she returns to most often.
But then, in August 2018, they were gone. On a Monday, she was diagnosed with stage-three breast cancer. On the Friday of the following week, she had a double mastectomy. She was only 41. The Sunday before her surgery, she came across an old friend from college while scrolling Tinder. An idea started to form. “I’m like, You know what? Somebody needs to play with these before they’re gone,” Williams said.
She went over to his house to have dinner and catch up. He told her how he’d recently been diagnosed with type-one diabetes, and when she sympathized, he said, “It’s okay — it’s not like I have cancer.” There was her opening. She told him everything, including about the sexy send-off for her breasts that she’d been secretly yearning. He was game, and they had what amounted to an intentional one-night stand. “It was great,” Williams said simply. A few days later, alone in her bathroom, she hiked up her black cami and took a mirror selfie of her breasts. Her cancer was only in the left one, but the decision to have them both removed had come easily. What were they really for, anyway? Her younger self would be shocked at how much fun she’d had with them, that’s for sure. She grew up Mormon, understanding the female body’s greatest purpose as producing and nurturing children. Part of her still thought of her breasts that way. “So I don’t need them,” she told herself at the time, given how sure she was that she did not want kids. “They’re pointless.” It didn’t feel like a big deal to let her breasts go, especially since she would replace them with a solid pair of dupes.
A few days later, she had her double mastectomy, and in the same surgery, her plastic surgeon began the reconstruction process. He placed tissue expanders underneath the skin that once held her breast tissue; these durable plastic pods — each with a magnet at its center — would gradually stretch her traumatized skin and muscle to create enough space for permanent silicone implants. Every few weeks (after her initial recovery from the surgery), her plastic surgeon would inject the expanders with saline until they reached the size of her desired breasts. After that, her incisions would be reopened and the expanders would be swapped out for implants.
In the weeks just after surgery, everything seemed fine. She’d arranged to take five weeks off work — she was a recruiter at a big staffing agency, a job she’d had and loved for nearly 20 years — and so she watched a lot of reality TV and posted to the private Instagram she used to keep her friends and family updated. In a photo taken a week after her expanders were placed, Williams grins as she poses in a pair of cute boxer shorts and a surgical bra. She holds up two surgical drainage bags filled with blood and pus, smiling. Honestly, she’s kind of pulling the look off. (“All I see is your perfect brows and lashes,” one friend commented.) Her biggest post-op annoyance was her sister and two close friends, who all stayed with her for a week and hovered over her every move.
Three and a half weeks after that photo, the trouble began. One morning, she was headed to the bathroom when she felt a stream of liquid running down her torso. “I mean, fluid was just pouring out of my body,” she said. She didn’t know what to do — it just kept coming. It smelled awful, and it looked like the stuff that oozes out when you pop a zit. She ended up leaning over her bathtub so it could drain out. She had emergency surgery the next day, during which her doctor identified the culprit: MRSA. Her chest was full of it. The surgeon removed the expanders, leaving Williams’s chest flat. He told her she would have to stay that way for about a year, through chemo and radiation and three more surgeries.
Being flat didn’t faze Rhonda. All of it — including the cancer — felt like a temporary setback. She was determined to speed through cancer as quickly as possible so she could return to her life, looking almost exactly the way she’d left it. “I honestly thought this was going to be a blip on my radar,” said Williams, who is now 48 and lives in Utah. “I was like, Well, it’s going to be a real crappy few months,” she said. “And then I get implants for free. Yay!” She continued: “And that is not how it went. That’s not how it goes for almost anybody.”
Around 40 percent of mastectomy patients opt for reconstruction, according to a 2023 study in the Annals of Surgical Oncology. That’s up from 8 percent in 1995. The increase is often credited to the Women’s Health and Cancer Rights Act, which passed in 1998 and requires health insurers to cover breast reconstruction. It can also likely be attributed, at least in part, to the rise of prophylactic mastectomies in women who have elevated genetic risks for breast cancer. Last year, a team of researchers published a review of 99 studies on breast reconstruction and psychological well-being, most of which showed that reconstruction improves breast-cancer patients’ overall mental health. Yet many patients say they felt underprepared by their doctors for the length and intensity of the breast-reconstruction process. Up to 40 percent of women who undergo breast reconstruction end up dissatisfied with the results.
In 2018, Dr. Edwin Wilkins, professor emeritus of plastic surgery at the University of Michigan Health, co-authored what is still considered by many in the field to be the best available research on complications from breast reconstruction. It followed about 2,300 women who had breast reconstruction at 11 medical centers in the U.S. and Canada, finding that one in three women who have breast reconstruction will have some sort of complication, often requiring additional surgeries or hospital stays. Dr. Andrea Pusic, chief of the division of plastic and reconstructive surgery at Mass General Brigham in Boston and another author on the study, now believes that number is probably more like one in four, crediting improvements in mastectomies, infection prevention, and patient selection.
“To me, the risk of a complication is the Achilles’ heel of breast reconstruction,” said Dr. Clara Lee, a plastic surgeon and professor at UNC School of Medicine. “It’s a really important operation. It has the potential to restore quality of life. It’s critical to at least offer it to women who are candidates. But there’s this relatively high complication risk, and we are doing things to make it better, but we haven’t quite gotten there yet.” For some women with breast cancer, that complication risk means undergoing multiple unplanned surgeries in pursuit of rebuilding the breasts they lost to cancer. And even if everything goes well, with minimal or even zero complications, almost all breast reconstructions will involve multiple “revision” operations. “Mastectomy reconstruction is rarely one and done,” said Wilkins. “These are complex, multi-staged operations that require considerable skill from the surgeon and perseverance from the patient.”
Just weeks ago The Home Edit’s Clea Shearer posted on Instagram about her 15th reconstructive-breast surgery in three years — and her fourth in two months. “In the operating room, my doctor discovered my breast expander, and the surrounding area, was fully infected … I’m back to being flat on my right side and have my drains back in. Needless to say, I’m feeling pretty heartbroken right now,” she wrote, then added, “I WILL achieve reconstruction at some point, but nothing is more important than my health. I always say to prioritize it, and I’m taking my own advice. Onward.” Williams can relate to her seemingly unstoppable drive to reconstruct her breast. She, too, has had 12 surgeries related to breast reconstruction — but in the span of just two years.
What drives some women to persist through so many years of so many surgeries? Why prolong your time in Cancerland — or, if not exactly Cancerland, than in an adjacent world of hospitals, stitches, bandages and drains, bad sleep, and pain medication, not to mention days or weeks at a time away from work, friends, and family? It’s difficult to understand unless you’re in it, and even then many of the women I spoke to found it hard to articulate. Dr. Monique C. James is a psychiatrist at Memorial Sloan Kettering Cancer Center who works with patients undergoing mastectomy and reconstruction; it’s part of her job to help them understand their own motivation. “Where it gets hard,” she said, “is when people have assigned meanings to their breasts that connect to their identity.” She starts her relationship with these patients by asking each one the same question: “What do your breasts mean to you?” Just like breast reconstruction, the question is often more complicated than it seems.
When you have breast cancer and need a mastectomy, well-meaning friends and family will often make the same well-intentioned joke: Hey, at least you get a free boob job! Many patients, too, assume at first that breast reconstruction will be just like breast augmentation. I asked Wilkins how often he has heard patients conflate the two. “Oh gosh. Constantly,” he said. “But it’s understandable, and even sophisticated, well-educated consumers don’t, or at least can’t initially, tell the difference.”
Many patients who had undergone mastectomy told me they got this idea, at least in part, directly from their plastic surgeons. In consultations, their surgeons often used language that the patients associated with cosmetic procedures. Kerrin Engebretson, who’s 42 and lives in Elk Grove, California, was excited about the idea of a flap reconstruction — with a tissue transfer from her thighs — after hearing her plastic surgeon describe it. “She told me, ‘This will end up really helping the contour of your thighs, because it’ll tighten them up,’” said Engebretson, who had the first surgery for her reconstruction immediately following her prophylactic double mastectomy in January 2024. “And I was like, Oh, okay — kind of like getting a thigh-lift at the same time.” Engebretson is happy with her results now, but she first had to get through five reconstruction-related surgeries, including multiple hospital stays and one incision infection that nearly put her into sepsis. For her, the comparison to a cosmetic procedure obscured the fact that many flap reconstructions require corrective surgeries.
Some surgeons are aware that using language associated with cosmetic surgery could compromise their ability to manage patients’ expectations. “I think the advantage of using those terms is that a lot of people understand what they mean,” Lee said. It’s nice to have any sort of shorthand, especially considering the fact that cancer treatment tends to move at a head-spinning pace. “But the downside,” Lee added, “is that people may then unconsciously start to associate breast reconstruction with these procedures, which they are not.”
The real difference between breast augmentation and reconstruction is the cancer, obviously. But more specifically, the mastectomy is a big complicating factor. “A breast augmentation takes a normal, lovely breast and then puts an implant behind it,” said Pusic. With a mastectomy, the plastic surgeon is essentially starting from scratch. “We’re taking out all the breast tissue and leaving behind only skin,” Pusic said.
Through the 1960s and to some extent, into the ’70s and ’80s, mastectomy and breast reconstruction were routinely performed in separate surgeries, leaving an in-between period during which patients would have to live with what’s known as the “mastectomy defect,” a period of being flat chested (or even concave) after the breasts are surgically removed. It wasn’t until the 1990s that immediate reconstruction — when the breast surgeon removes the breast tissue and then the plastic surgeon comes in to begin the reconstruction, all within the same operation — became the norm. “The whole point of that is so women don’t have to bear the brunt of the defect,” said Dr. Carolyn De La Cruz, chief of plastic surgery at UPMC Shadyside in Pittsburgh. “We don’t want people to have to feel bad about their bodies … and so if people wake up and they have breasts and they never felt the grief or the loss, then we consider that a good thing.” (For their part, patients told me that even without a period of complete flatness, the loss of their breasts is still blatantly apparent.)
The two surgeons — the breast surgeon and the plastic surgeon — have related but competing goals. The breast surgeon wants to excise the cancer and lessen the risk of recurrence, and to do that he must remove all the breast tissue. The plastic surgeon wants the breast surgeon to leave enough skin and subcutaneous tissue behind so he is able to use it to re-create natural-looking breasts. The tricky part for the breast surgeon is that breast tissue looks a lot like the subcutaneous tissue located right under the skin. “A lot of times it’s really hard to figure out which is which,” said Dr. Laura Dominici, a surgical oncologist at Dana-Farber Cancer Institute in Boston. To ensure all breast tissue has been removed, some breast surgeons may err on the side of taking too much subcutaneous tissue, leaving behind paper-thin skin.
Too-thin skin is more prone to infection and necrosis (skin death), because too much of the blood supply to the skin has been removed. “If the breast surgery destroys the skin, I’m handcuffed. I can’t do it,” said Dr. David Song, who is vice-president of medical affairs and chief medical officer at MedStar Georgetown University Hospital in Washington, D.C. He recalls instances during his career when he’s worked with inexperienced breast surgeons, who didn’t leave him enough to work with. “I walk in, and the skin’s remaining, but you can shine a light and read a magazine through it,” he said. “In those situations, I’ve had to abort the reconstruction.” A hidden indicator of how successful a breast construction will ultimately be may be how well the breast surgeon and plastic surgeon work together. Dominici told me: “Plastic surgeons are great. But sometimes they have varying levels of understanding about the cancer part of the operation.”
In a reconstructed breast, as compared to an augmented breast, no breast tissue is left to support or hide the implant, and that — plus the potentially thinner skin — can increase the likelihood of aesthetic or structural problems. “My breasts look like deflated water balloons,” Oksana, who’s 30 and lives in Toronto, told me. By that, she means that she has a common problem known as rippling — where the implant’s surface becomes visible under the skin, making the breast appear empty and wrinkled at the top. Her reconstructed breasts, which she got in March of last year, are saggier than she expected, too, possibly due to a lack of internal support for the implants. “It looks like I’ve been breastfeeding,” she said. She had a revision in mid-February and when we spoke in early June, she already knew she would be scheduling another.
She told me she has little interest in finding alternative ways to feel attractive. “My whole mentality is that I feel like I’m too young to just accept not being happy with what my body looks like,” she said. For now, she wears a bra practically at all times. Even during sleep. Even during sex. Her boyfriend, who she’s been with for nearly six years, has only seen her breasts a handful of times since the reconstruction process began nearly a year and a half ago.
Photo: Courtesy of Rhonda Williams
Then there is the problem of the cancer treatment itself — particularly radiation, which can pose problems for reconstruction by damaging skin tissue. By the time Williams was cleared to restart the reconstruction process the summer of 2019, she had fewer options than she’d had a year prior when her expanders were placed. “My skin had been radiated to shit,” she said. In addition, the skin tissue on the right side of her chest — the non-cancer side — had been weakened after a relentless series of infections. Her surgeon laid out the remaining choices. A fat transfer from her stomach could get her to something around an A cup, and a transfer from her buttocks could get her to a small B. But it was also possible her skin was too paper-thin to support those options — and what Williams really wanted were her C cups back. For that, her best bet was a latissimus dorsi flap: Her surgeon would carve two crescent-moon-shaped slices of fat, muscle, and skin out of the biggest muscles in her back and tack them on to her pectoralis muscles in order to support her implants.
Williams started that process in August of that year when her surgeon removed the tissue from her back, attached it to her chest, and placed a new pair of tissue expanders to make room for additional implants. Most doctors recommend taking a minimum of four weeks off after a surgery of this nature, but Williams had promised her team she’d be back in a week. It had been a weird year at work, she told me. She was good at her job, and she was well liked, but in January her boss had informed her that her team hadn’t budgeted for her salary that year. After some confusion, she had landed on an adjacent team — in learning and talent development — and it wasn’t going great. Williams ended up taking only three days off after the back surgery, working from her bed and propped up by a fortress of pillows.
A series of calamities followed that fall. One of the expanders sliced through the stitch, requiring yet another surgery. In October, midway through a surgery to swap out the expanders for implants, her surgeon deemed the skin on the right side of her chest too fragile. She put the left implant in, but kept the right side flat. Around this time, her doctors connected her repeated infections to one of her chemotherapy drugs, a known but rare side effect. It could take up to a year for the drug to fully leave her system, and until it had, her plastic surgeon refused to place the other implant. Williams had gone into that surgery, her seventh, believing it would be her last. Instead, for the next eight months she walked around with a reconstructed breast on her left side and a piece of her back muscle tacked on to her right. She got a prosthetic, which she used when she didn’t want to answer nosy questions; she learned to strategically arrange big scarves.
Somewhere in the middle of all that, a close friend suggested that she take a break from all the surgeries. “‘I think your body needs more time to recover,’” Williams remembers her saying in the group chat. She understood what her friend was trying to say, but still: She was highly annoyed. This friend had had a nose job plus multiple revisions; Williams had driven her to more than one of them. “And I absolutely thought, That was unnecessary, but you didn’t ask me my opinion, so I didn’t give it,” Williams remembers thinking. Why was one aesthetic quest okay and not another? Anyway, it wasn’t like Williams was chasing a makeover; she just wanted back the breasts she once had — a result her surgeon still believed was possible and so she did, too. Williams and that friend no longer speak.
When Natasha Genders thinks about her breasts and what they have meant to her, she mostly thinks about breastfeeding. In a very real way, breastfeeding her youngest child saved her life when what appeared to be a persistent case of mastitis turned out to be cancer. She was only 26. She opted for a double mastectomy, followed by reconstruction with implants.
About eight months later, she was at work when she realized something was wrong. She’d recently gotten her nursing degree and was assisting in an orthopedic surgery, helping to transport a patient, when she felt a sharp, sudden pain in her right breast. “It felt like I’d gotten shot in the chest,” she said. The pop Genders felt was surgical mesh tearing away from its anchor point. “So [my implant] was just loose in there,” she said. The tear was due to capsular contracture, a common complication that causes scar tissue to tighten around an implant, and it would require another surgery to fix. Genders was told to take six weeks off work to recover. She was only able to take one.
Then, last winter, she was working in the ICU, trying to help intubate a patient. As she reached to hold down the patient’s shoulders — pop! The same shot-in-the-chest sensation as before, only this time she knew what happened. A visit with her doctor confirmed it: The surgical mesh had detached again. She would need another surgery — her fourth — to correct it.
Not long ago, a thought occurred to her: Mastectomy is a necessary medical intervention. Breast reconstruction is optional. Already, she thinks she lost out on a job offer because she had to take so much time off work, and she suspects that being intubated during one of her surgeries caused a chipped tooth. “Not being able to work, not being able to make money, pay my bills — it was all so overwhelming,” she told me. “And it’s like, What am I fighting for?”
Her objective was to speed through the reconstruction as fast as possible, so her kids wouldn’t have to worry about her. She wonders now if that’s why she didn’t ask many questions about the reconstruction. Plus, she thought it was supposed to be the fun part. Of her plastic surgeon, she says: “He’s all hyped up and excited. You know, ‘You’re getting new breasts!’” The optimism was a tonal shift from the dour conversations she’d had with her medical team for the past year, and she started getting excited, too. Together, the two of them perused her implant options (“That part was cool,” she said); the reconstruction, he promised, would quickly have her feeling and looking back to normal. “He was like, ‘You got through the worst part — now you’re almost at the end,’” said Genders, who is now 32 and lives in King George, Virginia.
In reality, the reconstruction has heavily prolonged cancer’s imposition on her life. With her limited arm mobility caused by the capsular contracture, she has a hard time performing CPR at work (though she does it, anyway); at home, she can’t practice baseball with her son or pick up her youngest daughter, who is 7. When the pain has gotten really bad, her oldest daughter, who is 14, has helped her get in and out of the shower. “You don’t want your kids to see you like that,” she said.
Genders wishes her first surgeon had emphasized the risks, especially the impact radiation could have on the outcome of a reconstruction. “Not just the good parts,” she said. Her next surgery will not be about aesthetics, or at least not entirely; without it, she won’t regain full use of her right arm. Still, she’s been putting off scheduling it. Her surgeon wants to try placing the implant under her pectoral muscle instead of on top of it, which could lessen the likelihood of capsular contracture occurring again. But this procedure requires a longer recovery time, and Genders has no idea how she’ll be able to take three months off work.
So she’s learning about other options: For one, she can have surgery to remove the implant and then have an aesthetic flat closure. She’s also looked at the prosthetics on offer from her doctor, which would be worn under her clothes. They could be okay. Part of her wants to roll the dice and try one more time for reconstruction. “It could be the one time that’s, like, Okay, it worked. And now I can go back to normal,” Genders said. Another part of her wants what she’s wanted all along: to move on.
Among both breast-cancer patients and the general public, knowledge about reconstruction is spotty. A 2022 survey by the American Society of Plastic Surgeons showed that more than half of women surveyed weren’t aware of options other than implants — such as “going flat” with an aesthetic flat closure, using a prosthetic breast, or having a lengthy DIEP flap surgery, in which the breasts are reconstructed from abdominal fat. And nearly three-quarters were unsure of whether they’d be on the hook for the cost of the surgery. In a 2017 study, Lee found that the majority of patients don’t make decisions about reconstruction that are both fully informed and also align with their actual preferences. Some who said they valued avoiding complications — and also said they didn’t really care about having a visible breast shape when they’re not wearing clothes — still chose to have reconstruction, for example.
If you ask women who’ve been through mastectomy and reconstruction what drove them to persist through multiple reconstructive surgeries, many of them end up talking about the mastectomy instead: They’ll say something like, “It was important to do everything I could to stay alive for my kids, for my grandkids, for myself.” Perhaps because the mastectomy and reconstruction happen during the same procedure, some seem to mentally combine the two. Part of James’s emotional work with patients is to untangle these procedures, which can help them identify and grieve what they’ve lost.
The question James poses to her patients — “What do your breasts mean to you?” — is deeply personal, and everyone has a different answer. At baseline, many women seem to hold an inherent belief that to be feminine, breasts (or, rather, reconstruction that approximates breasts) are a requirement. Just as mastectomy (or “top surgery”) is gender-affirming care for trans men, some consider reconstruction to be gender-affirming care for cis women. “I had one patient who had really stepped into a ‘feminine power’ thing,” James said. She was a high-level executive at a big company, and she liked the way her cleavage-baring suits subverted the idea of masculine power. “She loved the fact that her breasts kind of led her into different rooms and different events,” James said.
Sometimes, patients tell James it’s the first time they’ve considered what their breasts mean to them and what it might mean to live without them. Once they’ve thought it through, it’s often easier to help people find alternative ways to reconstruct that meaning. “We work on acceptance — that for whatever reason, we’re in this cancer world now together,” James said.
Occasionally, plastic surgeons see patients who demand more and more revision surgeries to correct what appear, to them, to be minor imperfections. Song told me, with some exasperation in his voice, that with or without reconstructive surgery, almost no breasts are perfect. “I mean, if I took 100 women off the New York City streets that had never had breast surgery, 99 of them are going to have some asymmetry, right?” he said. Wilkins has a theory: For some, the quest for flawlessly reconstructed breasts might be an unconscious attempt to put cancer behind them or to erase the fact that it ever happened at all. “In the end, reconstruction cannot give the patient what we would all miraculously like them to have, which is to turn back the clock and make it look like nothing ever happened,” Wilkins said. “I can’t make you feel like you never had to go through this.”
When he talks to his patients about the pros and cons of reconstruction, he often cites his research on the likelihood of complications. “Now, did I scare some of them off? Yeah, I’m sure I did. But that’s entirely appropriate,” he said. “Is going flat a better option? Well, by all means, that is an option, and I would also talk about that with patients as well.” But many plastic surgeons still consider their rate of reconstruction as a measure of success — and don’t spend much time discussing the flat route at all.
In the beginning of her journey with breast cancer, the last thing Williams wanted was to let the experience change her. She wanted cancer to be a quick detour, and then she wanted to pick her life back up the way she’d left it, fantastic boobs and all. Her belief that she could return to her old life is largely what compelled her to persist through so many surgeries. She doesn’t believe that anymore. “I just don’t think anybody who hears the words, ‘You have cancer,’ is ever the same,” she told me.
She has implants where her breasts once were now, and she hates them, even after all she went through to get them. Despite 12 surgeries, the right side sags to the side (“It’s basically in my armpit,” she said), and although her surgeons were able to preserve her nipples, she now wishes they hadn’t bothered. Instead of being located at the center of her breasts, they’re on the sides. They’re also ghostly pale, because they have no vascular response. “They do look like nipples, sort of,” Williams said. “I mean, picture yours, but with no feeling and no color.”
Her plastic surgeon is a perfectionist, who recently told her that an additional fat transfer could help with some of the sagginess. Williams is intrigued, especially because she wants her nipples removed, and her surgeon said she could do both at the same time. She needs a job with better health insurance first. After the last surgery, a combination of lingering chemo brain and burgeoning depression made it impossible to continue on in the job she used to love, and so she left. She isn’t sure what she wants to do next. (When we last spoke, she was finishing up a shift delivering packages for Amazon.)
When she contemplated her surgeon’s proposal, though, there was a glimmer of hope. “I’d like to feel attractive again,” she said. Since the mastectomy she’s had sex once, but it was awkward and he ghosted her afterward. Sometimes she thinks it may never happen again. “I don’t like the way I look. And I don’t know how to start,” she told me. Once, her breasts were representative of her confidence and independence; now they’re symbols of danger and loss. When she’s wearing clothes, she says she looks fine. But she’s taken to calling what’s underneath her Frankenboobs. “They’re just nothing like they used to be,” she said. “But I mean, but I’m alive, so, I guess there’s that.”
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