Once upon a time in America, in the late 1960s, a 13 year old girl became an orphan, and ran away to New York City. The girl became an artist’s model, and the artist’s model became an artist. Having travelled to Europe where she circulated amongst the ‘hip and infamous’, she returned to New York, spending the ‘80s variously publishing her memoirs, exhibiting her art, and performing as lead singer in a band. Ultimately she decided to focus on photography, and published a series of self-portraits – Ruins – to critical acclaim. Then, in 1991, on the crest of a wave of professional success, she was diagnosed with breast cancer. The artist became an activist, creating provocative drawings and posters to support the emerging breast cancer campaign. In 1993, at the second Breast Cancer National Conference in Washington DC, she was spotted by a New York Times journalist wearing a sandwich board emblazoned with her self-portrait poster ‘Vote For Yourself’. The journalist, Susan Ferraro, wrote the story ‘The Politics of Breast Cancer’, and on 15th August, 1993, the New York Times published it in their Sunday magazine with a photograph of the artist on the cover, accompanied by the headline ‘You Can’t Look Away Anymore’. The artist was Matuschka, and her self-portrait of her mastectomy – ‘Beauty Out Of Damage’ – became one of the most controversial covers in New York Times history. It is, according to ‘Life’ magazine, one of 100 photographs that changed the world…
Until the closing decades of the 20th century breast cancer was still considered an unspeakable disease. It was the same New York Times that broke taboos with Matuschka’s photograph which, in the 1950s, refused to print an advert for a breast cancer support group because it would not print the words ‘breast’ or ‘cancer’. The death rate from breast cancer remained high and stagnant; a diagnosis was tantamount to a death sentence, and the disease was suffered in shame and silence. Then, in the context of a growing feminism movement, several well-known women bravely spoke out about their breast cancer. In 1972 the actress and former child-star Shirley Temple Black announced her diagnosis at the age of 46, and, in an unprecedented step, the then First Lady, Betty Ford, held a press conference to share the story of her diagnosis and mastectomy. Such was her reach and influence, that the consequent spike in diagnoses resulting from self-examinations became known as the ‘Betty Ford blip’.
The doctor can make the incision; I’ll make the decision – Shirley Temple Black
As well as going public with their experiences, women also began challenging the norms of breast cancer treatment. Babette Rosmond, a magazine editor, discovered and pursued breast preservation treatment instead of mastectomy. She was dismissed as “a very silly and stubborn woman” (i.e. a force of nature). Rose Kushner – another journalist – insisted on a diagnostic biopsy before any further treatment. Her book ‘Why Me? What every woman should know about breast cancer to save her life?’ was dismissed as a ‘piece of garbage’. They were heady, controversial times, and this was not a happy band of sisters. Frustrated by lack of progress and research funding, and jostling for focus and attention, the early breast cancer movement was uncompromisingly single minded and strident. Nancy Reagan was publicly vilified for her decision to have a mastectomy instead of breast-conserving therapy, and the incorrect hypothesis that abortion increased the risk of breast cancer set breast cancer activists against abortion advocates in the ‘breast cancer wars’.
However, by the 1990s, inspired by AIDS activism and recognising the power of organised, collective action, breast cancer activists started to form a more united front. In 1992 – spearheaded by the Susan G. Komen Foundation, and with a little help from Estee Lauder – the modern pink ribbon movement was born. And, for anyone who doubts the long term implications of a US Presidential election on the world, it was the 1992 election of Hillary Clinton’s husband Bill, who was progressively sympathetic to women’s causes, which cemented breast cancer as a national political priority. Under pressure from the National Breast Cancer Coalition – and perhaps influenced by his own mother’s diagnosis – in 1993 Clinton established the National Action Plan on Breast Cancer, and an extra $210 million was dedicated to breast cancer research. As the rest of the world followed the United States’ lead, the breast conserving ‘garbage’ put forward by ‘silly’, ‘stubborn’ trailblazers like Babette Rosmond and Rose Kushner became common practice in early stage breast cancer care.
No man is going to make another impotent while he’s asleep without his permission, but there’s no hesitation if it’s a woman’s breast – Rose Kushner
While the burgeoning breast cancer movement was finding its voice in Washington, there was another important breakthrough emerging for breast cancer patients that had its origins in 1950s Hollywood…
Miracles of Shape and Density
Breasts have long been a source of fascination, and a bellwether for the prevailing attitudes and fashions of the time. Ancient Greek Goddess Hera is said to have worn a classical Wonderbra with ‘brooches of gold’ and a ‘hundred tassels’ to distract Zeus from the Trojan War, and, in more recent history, the French long regarded the display of breasts as a sign of beauty, wealth and aristocracy; bare legs, shoulders or (ye gods) ankles were considered far more risqué. The Victorian response to this was, naturally, to cover absolutely everything, with chest flesh considered the preserve of ‘actresses’ and fallen women. Clergymen were globally outraged by the development of shallow round-necked fashions in the early 20th century, and the roaring, rebellious ’20s saw women bind and bandage their breasts to appear more boyish. Then, in 1953, in another iconic image that would play its own small part in changing the world, Jane Russell and Marilyn Monroe stood corset to curvaceous corset as Dorothy and Lorelei in ‘Gentlemen Prefer Blondes’. The breast was back, and it was big, busty and packed into a ‘bullet bra’.
Marilyn’s bosom was famously described by Billy Wilder as a ‘miracle of shape, density, and an apparent lack of gravity’, but most women had to resort to ‘falsies’ – a variant of the prosthesis – stuffed into their bras to emulate the ‘look’ of the decade. Doctors experimented inserting sponge implants, but they shrank and became ‘as hard as baseballs’. Then, in what must have been a particularly slow day at the office, a surgeon, Frank Gerow, noticed the (apparent) similarities between a blood bag and a woman’s breast, and – in a creative leap of the imagination – invented the silicone implant. Gerow and his colleague Thomas Cronin completed their first pioneering silicone surgery on Esmeralda the dog, who was delighted with her cosmetic result, but chewed her stitches so had to have her implants removed. Esmeralda was followed by a real, live woman – Timmie Jean Lindsey – who received the first silicone implants in Houston, 1962.
Breast augmentation swiftly became a reality, and the 1970s saw mass production and refinement of silicone and saline implants, and increasingly consistent results. In a shining example of the cross-pollination of medical disciplines, cosmetic enhancement of healthy breasts paved the way for breast reconstruction – the rebuilding of breasts impacted by cancer. In 1971 the first immediate breast reconstruction was performed, where a silicone implant was placed under the chest wall skin immediately after mastectomy, and in the 1980s expandable implants were developed which could be gradually inflated over time in patients whose skin had been compromised by mastectomy and radiotherapy. However, the late 1980s and early 1990s saw increasing concerns raised related to the first generation silicone implants, which had been found to leak. Consequently, in 1992 the FDA banned silicone implants for all procedures except post cancer reconstruction, and onco-plastic surgeons increased their focus on the possibilities of autologous reconstruction; using the body’s own tissue to rebuild the breast.
Ironically, the silicone implant scandal peaked at around the same time that breast implants were popularised in the mainstream media. In 1990 Madonna resurrected the conical ‘bullet bra’ for her iconic Blond Ambition tour, and in the same year new Playboy playmate Pamela Anderson underwent breast augmentation. Two years later, she joined the cast of a once-failing show about LA lifeguards. Baywatch became the highest grossing TV show in the world, watched by 1.1 billion people in 148 countries. As lifeguard CJ Parker’s bouncing, ball-shaped breasts were beamed into living rooms around the world, Eva Herzigova stopped traffic in her ‘Hello Boys’ Wonderbra, and the lads mags celebrated a decidedly busty aesthetic. Breast augmentation became cemented in the public consciousness as an aspirational, but accessible, cosmetic procedure, and Pamela Anderson came to represent the archetypal boob-job body.
Times have changed since 1994. The lads mags are no more and, having reached peak-boob in 2006, breast surgery is declining in popularity, with a number of notable celebrities, including Pamela, exchanging their double-Ds for a more ‘natural’ look, though the red swimsuit is about to rebooted in ‘Baywatch the movie’ so watch this space. Whatever 2017 may bring us in the way of big screen breasts, I think it’s time to give Baywatch the serious feminist plaudits it deserves, not only for showing almost as many muscly men in shorts as it did semi-naked women, or for demonstrating that anyone can get into a perilous water-based situation, or even for proving that women can run just as fast as men on sand, even when their swimming costume is uncomfortably short in the body. Aside from all this (and surely this is enough), the ongoing popularity of cosmetic breast surgery has helped to make breast reconstruction a reality for the majority of breast cancer patients. CJ Parker, we salute you.
Here comes the science bit
There are several flavours of breast reconstruction depending on the circumstances, and they can be immediate – performed at the same time as lumpectomy or mastectomy – or delayed until after treatment is complete. A straightforward implant reconstruction is the simplest and most common technique. The alternative is a ‘flap reconstruction’ using tissue from another part of the body – the back, bottom, thigh or stomach – either alone or in combination with an implant, to rebuild the breast. An ‘LD’ flap reconstruction requires skin, fat, and a section of the lattimus dorsi back muscle to be removed from the back, fed under the armpit, and repositioned on the chest to reconstruct the affected breast. In a ‘free flap’ reconstruction, a flap of skin, fat, and occasionally muscle, is removed completely from the tummy, buttocks or thighs, and transferred to the chest where specialist microvascular surgery is used to reconnect the tissue to a blood supply in the chest, and build a new, ‘live’ breast. And, in a nipple reconstruction, a portion of the opposite nipple is used to craft a new one, or flaps of tissue from the reconstructed breast are raised and sewn together, origami-like, into a nipple shape.
If that all doesn’t sound extraordinarily complicated then I haven’t done it justice. Onco-plastic surgeons are at the cutting edge of plastic surgery, performing restoration on a canvas that has frequently been damaged by cancer, weakened by chemotherapy, and burnt by radiation – and the popular image of ‘plastic’ surgery is increasingly a misnomer given the sophisticated techniques that are employed to transplant live tissue from one part of the body to another.
Of course, no surgery comes without a price, and reconstruction is no different. Reconstruction surgeries can take anything from 2-3 hours for a breast implant, to 8-10 hours for a free flap, which also requires a week in hospital and 4-6 months recovery time. And even the ‘simplest’ breast implant operations come with a risk of complications – delayed wound healing, rejection of the implant, or capsular contracture where scar tissues hardens around the foreign object. For a breast that has been subject to cancer treatment, in a patient who has been subject to cancer treatment, the risks of complication can be significantly increased. And the thing about the complications on a consent form, however unlikely and obscure they sound, is that they are there because they have happened to someone, and I happen to know this because a fair few of them have happened to me. So, while the ultimate result of a breast reconstruction might be beautiful breasts that give CJ Parker a run for her money, it can often require multiple operations and, at the extreme, you may find yourself – as I did – in the eye of a perfect storm, undergoing emergency deconstruction to avoid a life-threatening infection.
Which is not to say I am not an enormous fan of breast reconstructions, because I am; reconstructive surgeons are modern-day miracle workers, and they deliver life-changing results, but they aren’t necessarily for everyone. I’ve had 7 surgeries, 5 reconstructions, 4 implants, 3 mastectomies, 2 deconstructions, 1 LD flap, 1 DIEP flap, and a partridge in a pear tree – which, given I started with just two breasts could be considered excessive, if not plain greedy. I’ve been flat, asymmetrical, perfectly formed, inflated, deflated, and pretty much every alternative in between, occasionally in a single day. And what I have learned is that there are no ‘right’ or ‘wrong’ choices when it comes to reconstruction, there are just possibilities, preferences, and personal circumstances. Whatever type of breast cancer surgery you need to have, and whatever you elect to do subsequently, it ain’t none of it easy, and the least society can do is to respect your right to choose, and make you feel nothing less than awesome about whatever individual choice you make.
Where are we now?
As we approach the 25th anniversary of Matuschka’s groundbreaking photograph the landscape of breast cancer is almost unrecognisable; survival rates have doubled, treatment possibilities have been transformed, research has accelerated exponentially, patients have been empowered, and the public has been informed. And yet, I believe that the stigma attached to mastectomy persists, albeit expressed in different ways, and there is a contradiction hiding at the heart of all of our apparent progress.
Ours is the era of diversity and inclusion, yet identity is increasingly reduced to category and caricature; ‘Cancer Patient’ can quickly become your single, defining attribute, even though the stereotype bears little resemblance to our many individual realities. Freedom of speech stretches further than ever before, and yet the information we consume is increasingly selected – and censored – by corporate giants. Mastectomy photographs were banned on Facebook until 2013, and many continue to be reported and removed on the basis they are “offensive”, and just last year Instagram deleted the account of the Pink Ink Fund for sharing photographs of post-mastectomy tattoos. So, while the sexual expectations of a generation are being corrupted by internet pornography, mastectomy is the nudity battle that the social media police have decided they need to fight. And the onwards surge of technology means we can now capture ourselves in such minute, mega-pixellated detail, and with such frequency, that appearance and reality are increasingly disconnected. Who we are, what we look like, and what we do is less about what’s real, and more about the enhanced and filtered social media picture we publish. There is limited allowance for difference and ‘imperfection’ because, with all of these tools at our disposal, there is no excuse for ‘imperfection’.
And so it is with mastectomy and reconstruction. It is a myth almost universally assumed that surgery for breast cancer always comes with a bonus boob job; that you can ‘just’ have a reconstruction, and so the mind-blowing ability of surgeons to recreate near-perfect breasts now risks inadvertently pushing mastectomy back into the shadows. We cringe when we hear the ‘M-word’ because mastectomy is a mirror in which we see reflected our deepest fears of loss – of health, vitality, femininity, independence, and, ultimately, of life. Reconstruction, on the other hand, represents our triumph over the disease; it speaks of gain, improvement and renewal. The possibility of reconstruction as the universal ‘antidote’ to mastectomy enables us to airbrush over the thing we find frightening and focus on the ‘fix’, even though it is the mastectomy that treats the disease and saves the lives.
The woman in the mirror
It goes without saying that all of my surgeries have been accompanied by a sense of loss and frustration. It would have been altogether preferable never to have had to contemplate them. But I know I am not diminished by them; if anything they have made me more. More experienced, more self-aware, and more comfortable in my own weathered skin. My scars are part of me, and to be ashamed of them in any way would be to be ashamed of myself. They are a chapter of my life, inscribed upon my flesh, and while they are not beautiful in the classical, or indeed modern sense of the word, they are hauntingly beautiful to me. When I look at them, in all their raw and high definition glory, I cannot help but feel awestruck wonder at all that has been possible, endless gratitude for all that has been achieved, and quiet pride in all that has been endured.
And when I look in the mirror I am acutely aware that I am one of millions. I stand, not in the shadow, but in the trailing stardust of all those who came before – the ones who spoke, and the ones who marched, and the ones who gracefully got on with the job of living, knowing deep down that society had handed them a raw deal. It is an extraordinary sisterhood that one in eight of us will join; enrolled through a common misfortune, united by a common experience, and motivated by a common cause. Thanks to those trailblazers of the 20th century breast cancer is now a disease whose name we dare to speak. It occupies a prominent, if not privileged, position in the public consciousness and is no longer suffered in hopeless, shameful silence. Yet there is so much left still to do – to protect the hard-fought progress that has already been made, to make sure everyone has access to the breakthroughs of the present, and to maintain momentum towards that holy grail of a therapeutic ‘cure’ for the future. The beacon is alight, and it is ours to carry on this leg of the relay. And so we must each press forward in our own way, with shoulders back and heads held high, to remind the world, lest it should ever become confused, that we are neither defined nor diminished by this ancient disease that has happened to us, and that real beauty – the kind that radiates like sunshine – is a beauty that reigns in spite of damage.
Ring the bells that still can ring
Forget your perfect offering.
There is a crack in everything
That’s how the light gets in
– Anthem, Leonard Cohen (1934 – 2016)
Links & References