Immediate Breast Reconstruction

Abstract

This article represents findings of a qualitative analysis of interviews with women age 30 to 64 years (n = 14) who had undergone immediate breast reconstruction (IBR) following mastectomy. The purpose of the study was to explore women’s experiences for electing IBR. According to our analysis, women experienced mastectomy as a disability, and their expectations of IBR to restore their sense of normalcy were not fulfilled. Most women perceived the reconstructed breast mainly as a visual replacement. Women’s experience formed a continuous narrative from the moment of diagnosis, through mastectomy until the completion of the reconstruction.

Keywords

breast cancer immediate breast reconstruction decision making mastectomy qualitative research

Introduction

Breast cancer is the most prevalent malignant disease in women in Israel as well as in other OECD countries. According to data from the Israeli Ministry of Health (2016), third of all diagnosed cancer cases are breast cancer; approximately 5,000 women are diagnosed each year. Women diagnosed with breast cancer must deal not only with the knowledge that they have a life-threatening disease but also with the psychological and physical consequences of its treatment (Bertero & Wilmoth, 2007). Moreover, in an age where numerous surgical treatments are available, women are often asked to make difficult decisions, such as breast reconstruction. According to the Israeli Cancer Association, 25% of women undergoing mastectomy opt for breast reconstruction.

Most studies on women coping with breast cancer have focused on the implications of surgical treatment, the assumption being that the more trauma to the body, the more severe the psychological distress (Moyer, 1997), especially in matters relating to body image (Fobair et al., 2006; Frierson, 2003; Hill & White, 2008; Thomas-MacLean, 2005), sexual function (Marshall & Kiemle, 2005; Wilmoth, 2001), anxiety, depression (e.g., Farooqi, 2005; Montazeri, 2008; Schlegel, Manning, Molix, Talley, & Bettencourt, 2012), and quality of life (Harcourt & Rumsey, 2001).

Studies examining the scheduling of reconstruction, both immediate (done at the same time as the mastectomy) and delayed, have reported on the psychological benefits of immediate reconstruction, especially in terms of quality of life, body image, and sexual function (e.g., Al Ghazal, Sully, Fallowfield, & Blamey, 2000; Ananian et al., 2004; Contant et al., 2004; Contant, Van-Wersch, Wiggers, Joe Wai, & Van-Geel, 2000; Wilkins et al., 2000). In particular, immediate reconstruction is thought to alleviate distress and depression, lessen feelings of loss of femininity, reduce damage to body image and self-esteem as well as the likelihood of dismay at the sight of one’s body (Holly, Kennedy, Taylor, & Beedie, 2003; Truelsen, 2003), and increase the chances that women will accept the reconstructed breast as an integral part of their body (Harcourt & Rumsey, 2001; Malata, McIntosh, & Purushotham, 2000). Some have even gone so far as to claim that the desire to undergo immediate reconstruction is itself a good predictor that women are adjusting well to the diagnosis (Harcourt & Rumsey, 2001).

In contrast, a number of studies, mostly qualitative, (e.g., Abu-Nab & Grunfeld, 2007; Guyomard, Leinster, & Wilkinson, 2007; Janz et al., 2005; Murray, Turner, Rehan, & Kovacs, 2015; Nissen et al., 2001; Roth, Lowery, Davis, & Wilkins, 2005, 2007; Rowland et al., 2000; Yurek, Farrar, & Anderson, 2000) have raised doubts as to the benefits of reconstruction in general and immediate breast reconstruction (IBR) in particular. They indicate that this procedure yields no more benefits than delayed reconstruction or forgoing reconstruction entirely and may even be detrimental to quality of life (Fallbjörk, Rasmussen, Karlsson, & Salander, 2013; Nissen, Swenson, & Kind, 2002; Wolf, 2004a, 2004b).

The arguments in favor of delaying reconstruction maintain that it allows women to cope with the diagnosis and the change in body image, mourn for the loss of the removed breast, and make decisions regarding reconstruction under less stressful circumstances. Thus, the reconstructed breast will be better assimilated into the new body image (Harcourt & Rumsey, 2001, 2004).

It has been argued that reconstruction is a reversal of mastectomy, one that can heal the psychological damage inflicted by removing the breast (McKean, Newman, & Adair, 2013; Wilkins et al., 2000). However, it has also been claimed that the breast is an irreplaceable organ and cannot be recreated (Crompvoets, 2012); hence, reconstruction merely substitutes breast texture and form (Rew, 2000), nothing more than an external replacement (Crompvoets, 2006; Nissen et al., 2002; Truelsen, 2003) that does not restore women’s lost sense of normality (Denford, Harcourt, Rubin, & Pusic, 2011).

In an attempt to better understand these discrepant views on the role of IBR in coping with the aftermath of mastectomy, the present study takes a phenomenological perspective to examine the experiences of women who elected to have IBR.

Method

Sample

The inclusion criteria were women who underwent IBR following mastectomy. Ads were posted on five Internet forums supporting women coping with breast cancer. Women with IBR were invited to take part in the study. The ad was reposted several times during the year 2006. All women who were willing to participate received information about the study in an initial phone conversation. Women who met the inclusion criteria were asked to sign a consent form prior to the interview. Two women were recruited with the help of the “Yad Lehachlama” (Reach to Recovery) organization, and two other women were located through personal acquaintance. Of the 14 women, one was omitted since she had a lumpectomy rather than a mastectomy, and another woman was omitted since she refused to have her interview included. The sample was diversified in all aspects. Women ranged in age from 30 to 64 years; half were between 40 and 50 years and a third between 50 and 60 years. Eight were married, three divorced and one single. Apart from the single woman, all had children. Women also varied with regard to the time passed from the original mastectomy and IBR surgery: from approximately 1 year (four women), through 3 years (five women) and up to 10 years (five women). Four women had bilateral reconstruction and the others unilateral reconstruction. Four underwent IBR that eventually failed for various reasons: Three elected for additional corrective surgery and the fourth chose to remove the implants bilaterally.

Research Method

A semistructured, retrospective interview, both recorded and transcribed, was held according to the guidelines laid down by Smith and Osborn (2003) for qualitative studies. The interview began with a general, open question (“Tell me about the process you went through from the moment you were notified of the diagnosis.”) to which each woman answered without interruption or interference. This was then followed by further questions regarding her detailed mastectomy experience (“Describe how you felt when you found out you would have to undergo breast surgery,” “Could you please tell me about the decision-making process regarding immediate breast reconstruction,” “Tell me how you felt after surgery,” and “Tell me how you felt about the immediate reconstruction”).

Data Analysis

Interpretative phenomenological analysis was chosen as it suited to study the experience of the women without any preconceived theories or assumptions. All interviews were transcribed by one researcher and then analyzed by two researchers according to the stages recommended for the interpretative phenomenological analysis method (Smith & Osborn, 2003). First, extracting sentences statements from each interview and then sorting them into groups to create emergent themes. Second, a comprehensive analysis designed to identify key themes which reoccur in the various interviews. This stage was done separately and independently by each researcher before forming super-ordinate categories. Finally, an integrative discussion of the findings along with possible interpretations was conducted. Both researchers agreed that the chosen themes represented accurately women’s experiences.

Findings

We identified five key themes that characterized women’s experiences: diagnosis, mastectomy, IBR, after the surgery, in retrospect. Each key theme was composed of subcategories that provided a broader, more complex picture of the significance of IBR in dealing with breast cancer.

Breast Cancer Diagnosis

This theme included two subcategories that were mentioned repeatedly in all the interviews.

The moment of discovery—shock and fear

All of the women described in great detail the moment they were notified they had breast cancer; they characterized it as a moment laden with information, a sense of shock, a feeling of being emotionally overwhelmed, accompanied by fear of death, and an unpredictable future. Some remarked that these feelings stemmed to a great extent from the way in which they were notified of their condition. At this moment, they were also told of the need for a mastectomy, which physicians tended to categorize as the worst news “I have good news and bad. I’ll start with the good news- the cancer has not spread … ; you’ll have to undergo a full mastectomy” [Ruth].¹

It runs in the family—a predetermined fate

The women who had known women who had breast cancer (family members, friends, or associates) noted this fact when describing their reaction to the diagnosis and stressed that their response, thoughts, and attitude regarding treatment were greatly influenced by this. One stated: “I knew for certain that I would be diagnosed with cancer,” and another said: “I was going to die like my mother and sister … ”

Three of the women knew they were at risk for the disease from their family histories. For them a diagnosis was just a question of time, it was predestined: “My whole life I knew that I was going to have breast cancer … and the day I was notified I had the sense of ‘I knew it!’ … It wasn’t a question of if, but rather of when”[Doris]. Another interviewee remarked “The oncologist … told me –‘this breast is susceptible to risk’ … so it was a self-fulfilling prophesy … my mother had it and then my sister had it, and my other sister … I’m bound to get it” [Sara].

Mastectomy

This theme yielded two subcategories that reflect an experience governed by dichotomized thinking.

The body: from wholeness to damaged

Awareness of the upcoming mastectomy prompted the women to think about the breast they had as well as how would they feel without it. Eight women indicated their positive relationship with the breasts. Some spoke of a feeling of acceptance, completeness, comfort, and pride: “I had the most amazing breasts” [Sara]; “I always took pride of my breast” [Mona]. They felt this even after the changes that occurred due to pregnancy and aging. The thought of losing their breasts brought about fear that the memory of the breast they had would fade which led some to an attempt to document the breast: “I had some photos taken, some nude photos … as a memento” [Ruth]. It is clear that this frame of mind was crucial in deciding in favor of reconstruction, as these women suddenly understood how significant their breasts were to them, and the next step was to imagine how life would be after the surgery, without a breast.

Prior to mastectomy, the women had difficulty imagining and accepting their appearance without a breast. Their description of a breast-less body formed three continuous categories: The first category on this continuum was physical and visual damage: “I think it’s an external flaw … damage to an organ of the body” [Rachel]; “It’s distorted and ugly … it’s a distortion of the body … a terrible ugliness” [Helen].

The second category involved the impact on body image and sense of femininity: “No one will want me as a woman without a breast” [Carol], “You lose all outward signs of your femininity” [Doris].

The third category focused on mastectomy as a handicap: “Without a breast I’d look like a cripple and I didn’t want to- neither to feel or look like a cripple” [Mona], “It looks very much like a handicap … something terribly unnatural” [Jane]. Images and representations of women without a breast as disabled also express a fear of social rejection and the stigma associated with disability, and this fear was strengthened by the idealization of the breast before the mastectomy. This view of mastectomy as a disability appeared to be central to the decision-making process, since the motivating factor for IBR was the wish to avoid feeling disabled.

Personal choice versus medical need

The decision-making processes were central to the experiences of the women since they had to cope with a diagnosis they did not control as well as a need to make a decision regarding the treatment. Thus, choice was perceived as power, as a way of exerting control compared with their lack of control over the disease. This can be seen in one woman’s statement: “(If you) want to go on living, you have to know how to be the author of your life story and not allow reality to lead you” [Carol].

Two distinct notions of the mastectomy appeared in the interviews:

For eight of the women the choice of having mastectomy was under their control as primary, secondary or preventive treatment. Two perceived mastectomy as a way for them to control their health: “This was an opportunity to get well and I had to grab hold of it with both hands” [Betty]. Three of the women elected for a mastectomy as primary treatment over lumpectomy as a way to “fight” the cancer: “As soon as the tests results came in I knew for certain that I did not want any breast tissue.” [Helen] This choice reflected the women's need to mitigate the fear of disease recurrence. Three other women elected to have a mastectomy as an attempt to change what they perceived as fate: “I wasn't sick, and I did it as a preventive measure. I feel that I did everything I could do to prevent it.” [Melanie]

For four women the mastectomy was not a choice but rather a medical procedure they were subjected to: “When they told me I needed a mastectomy, I didn’t care… now I’m doing everything I can to recover from it.” [Nora] Once the decision regarding mastectomy had been made the women had to decide whether they want to combine the mastectomy surgery with IBR. In other words, the IBR was the only intervention they could choose out of all the procedures done to their body (such as tests, treatments and surgical procedures).

Immediate Breast Reconstruction

It was apparent from the women that the choice regarding IBR was not an orderly decision-making process but rather a choice made under emotional duress; for the most part, their decision was influenced by the medical staff’s position. The majority of the women noted that the decision to have IBR was not a process (“There was no process at all. It was just obvious what had to be done. It was clear-cut”[Helen]), but rather a rushed decision (“I made the decision quickly. There was no time to think … there is so little time to decide, and the confusion and fear that go along with the diagnosis loom so large”[Betty]) which they needed to make while having to cope with various treatments. Women’s main consideration was the desire to avoid being without a breast.

Blurring the boundaries between the medical and the esthetic

The line between the medical and esthetic was blurred by the way the medical staff presented mastectomy and IBR as two related processes. First, the possibility of reconstruction was put forward almost in the same breath as the need for a mastectomy. Second, medical staff played down the health risks and emphasized the benefits: “My plastic surgeon calmed me down … If the body rejects the implant then it’s no problem, we’ll just remove it” [Mona]; “At no point did they stop and say- ‘look, these are the possible complications, don’t do this now, wait for later’. I received no explanation and heard about them only after having experienced each possible problem … ” [Ruth]

Finally, all the women said the physician recommended IBR: “They pushed very hard for reconstruction and doing it with the mastectomy. There wasn’t even a question of whether … the body needs to heal” [Doris].

The main consideration—avoid being left without a breast

All of the women said that a key factor in their decision was the belief that reconstruction would enable them to avoid having to deal with waking up without a breast and using prosthesis. However, closer examination suggests a more complex picture revealing their expectations regarding the outcome of the procedures: Their expectations range from masking the damage to the breast, as though nothing had happened (“They’ll do the reconstruction quickly and then I won’t see what really went on there”[Sara]; “Why should you walk around with a sign on your chest: Here is a woman … who had cancer” [Kate]), through avoiding collateral damage (“[The doctor said]: What if you get divorced … what if your husband isn’t willing to accept the mutilation? In any case it is detrimental to the relationship”[Melanie]), to gaining something good out of it (“Something good can come of this” [Mona]; “[The doctor said] after three pregnancies the breasts sag, they’re small, we’ll make them bigger, lift them … you’ll have the breasts of a 16 years old girl”[Rachel]).

The partner’s attitudes toward reconstruction as perceived by women

Most of the women raised the issue of their partner’s reaction as something they had taken into consideration. The partner’s responses ranged from resistance: “My husband wouldn’t hear of reconstruction, he said it was unnecessary and that I shouldn’t do it because of him or for him” [Mona], to support of any decision the woman might make: “It’s your decision and I’ll support anything you decide” [Rachel]. However, some of the women stated that they had not believed their partner’s statements reflect the real reaction had she decided against reconstruction: “You never know … when he really has to face it, he might respond differently” [Nora]. Two of the women said their partners took it for granted that they would elect for reconstruction. When one woman told her husband about the mastectomy, his immediate response was “But you will have … the reconstruction, right?” and added “I want the breasts you used to have” [Melanie].

After the Surgery

This category consists of women’s encounter with the reality of their choice of IBR.

The morning after—is IBR really immediate?

Although all of the women underwent IBR, most had a temporary tissue expander placed inside the breast which was to be inflated during the following months and then replaced by another surgery with a permanent one. For them, the IBR was not experienced as immediate but rather as “multi staged.” They hovered between disappointment and hope. Some were disappointed because they woke up without a complete breast: “It was just a little bulge … it was exactly the result I’d hoped not to see … it was as if they hadn’t done anything” [Ruth]; others felt hope at the sight of their new breast and saw the little bulge as the first step toward a complete breast: “Each time I went [to have the implant expanded] I was very happy to see it grow just a little, it was like the process of having a baby. It felt wonderful” [Carol]. It is clear that this “multi staged” immediate reconstruction was perceived by most of the women as a “prolonged procedure,” a process whose end results were not known in advance and did not always meet the expectations they had prior to surgery.

Women who had a tissue flap or permanent implant reported a different experience. These women remarked with relief and joy: “It looked natural … it was a good experience seeing there was no amputation. It was as if they hadn’t done anything at all” [Betty]. “You wake up with two breasts” [Sara].

Mirror mirror on the wall

Mastectomy and breast reconstruction were mainly perceived in visual terms, as “an image, not just a word,” as Ruth stated. Although no quantitative methods were used, we noticed increased use of words derived from the same semantic meaning as the verb to see in reference to mastectomy and reconstruction, such as saw, see, sight, look, appearance, and mirror. There were also words that related to visual perception: look, notice, image, and photographs. In contrast, words that refer to touch or tactility seldom appeared, and if so only when women described various stages after the reconstruction. There were almost no references made to the sense of touch or sensation in this regard, despite the importance of sensation, especially in intimacy. The emphasis of sight over other senses shows how vision and external appearance are central to the experience of mastectomy and reconstruction.

This emphasis on appearance manifested in one scene described almost identically in virtually all the interviews: The woman stands in front of her bathroom mirror, alone, and looks at her body. The mirror enables her to face her new body after the mastectomy. For the women, this recurrent theme of facing the mirror happened in three stages. First, an attempt to imagine the encounter: “I just wasn’t willing to see myself like that in the mirror” [Betty]. Second, seeing herself in the mirror without a breast: “Seeing the cruel truth every time you look in the mirror” [Betty]; “The first time I saw my reflection I simply fainted, it was a terrible sight” [Sara]. Finally, seeing herself in the mirror with a reconstructed breast. Each of the women experienced this differently: “Even now I still don’t look at myself in the mirror … only after I’ve put on a shirt” [Doris]; “When I see myself in the bathroom mirror I’m rather pleased” [Mona].

Moreover, several of the women who also had their uterus and ovaries removed compared this to removing their breasts. Both organs are significant to femininity and womanhood, the difference being that one is hidden and the other visible. This difference made coping with hysterectomy far easier: “You can't see it in the mirror; you don’t feel it's gone” [Rachel].

In Retrospect: The Meaning of Mastectomy and IBR

Some of the women felt at peace with the IBR and believed that it made coping with the disease easier. However, most noted that in hindsight they felt disappointed with their reconstructed breast, especially when their expectations based on their doctors’ statements did not jibe with reality. For those who suffered complications, there were moments of regret about having chosen IBR.

The reconstructed breast solely as a visual replacement

The reconstructed breast is only an external, visual replacement; it cannot replace the real breast because it does not feel like a real breast and because the women know the truth: “Visually it looks the same … but there’s some sort of trick here, an illusion, something that externally allows you to feel more comfortable” [Doris]. But beneath the clothes, the reconstructed breast is no substitute; it does not feel like a real breast and therefore cannot replace it, especially in intimate situations: “At no point will my husband caress my breast” [Jane]. Moreover, the internal sensation is also different: “Inside you feel something very empty, very lacking … I still don’t feel that it is a part of me…it’s my tissue, but there's no sensation” [Doris]. Seven of the women did not have nipple reconstruction, as they felt it was unnecessary. They felt the reconstruction had served its purpose in that it allowed them to wear all types of clothes and so externally no one could see the difference. However, three women chose to have reconstruction of the areola and nipple and only after these procedures they felt that the reconstruction was over: “As soon as you have the nipple reconstructed you can see something real … and after matching the color it’s a part of you and that’s it … I’m as perfect as before” [Rachel]. Another interviewee who has not had nipple reconstruction still feels that her breast is not real because of this: “This nipple thing really kills me … my breasts look like breasts … but as soon as you see the nipple you know it’s not natural” [Sara].

IBR advantages in coping with breast cancer

Some women felt the IBR helped them cope with their disease. This was ascribed to the following benefits of the procedure. First, it helps return to normal and continue with your life: “It happened, it’s over, I’ve forgotten about it so let’s move on” [Rachel]. Hiding the disease is another advantage: “It wasn’t that the disease was apparent in me … there’s a need to mask the signs of the disease” [Jane]. Finally, it masks the damage to the body and thus prevents having to deal with being without a breast: “I didn’t have to deal at all with … an amputated breast … I felt … that I always had two” [Nora], “The sense of loss … passed so quickly. It was enough to touch it with my hand and feel it there, to look in a mirror and see something there”[Rachel].

IBR leads to additional difficulties

For several other women, the IBR turned out to be a long and very painful process, one that made coping with the treatments, the radiation and the return to normal life even more difficult. Four of the women stated that their greatest hardship was the extraordinary pain that accompanied their gradual breast expansion: “The pain was unbelievable, pain that doesn’t give you a moment's relief” [Kate]. The pain made some regret their decision: “At some stage you regret it because you’re so wrapped up in the pain, and there are moments you feel suicidal” [Betty].

Three of the women experienced complications that included infection, skin damage from the radiation or necrosis, or failure of the reconstruction. All these were difficulties they would not have faced had they not opted for IBR. These women therefore had to face another dilemma of whether to have the implants removed and remain without a breast or have additional operations to correct the initial reconstruction. This involved another long and complicated process that had nothing to do with the disease: “Looking back on it now I think the cancer itself was less terrible … it was a much smaller problem” [Doris]. One interviewee had the implant removed and decided not to undergo another reconstruction. The rest chose to redo the reconstruction again and again over a period of years. One interviewee is still waiting for remedial reconstruction almost 7 years after the initial surgery.

Integration: A Continuous Narrative

An analysis of the findings reveals that the women’s experiences fit into one continuous narrative beginning with the moment of diagnosis and ending with the completion of the reconstruction process. This narrative reveals the significance each woman attributed to IBR in coping with cancer and how the reconstruction affects her current life. At the heart of this narrative lies the need to make decisions regarding medical procedures, and the emotional distress that accompanies such decisions. In other words, a continuous sequence is created, that of making decisions and dealing with their consequences. Within this sequence, the boundaries between the disease (breast cancer), the medical treatment (mastectomy), and the cosmetic surgery (breast reconstruction) became blurred. We assume that this blurred distinction between health and cosmetic considerations, necessary and elective surgery, stems from the way in which all three issues were presented by the physicians as integrated procedures to be carried out at the same time. All these led to an expectation that the reconstruction would compensate for the cancer and undo the mastectomy, an expectation that, for most women, was not realized.

Discussion

According to our findings, the association of mastectomy with disability stems from the meaning of breasts for women. When women imagine how they would look without a breast they refer to three categories that match the World Health Organization’s definition of disability (as cited in Arazi-Margalit et al., 2002): impairment (an organ is damaged due to illness that can be medically and objectively diagnosed); disability (impairment to function or to act, either physically or emotionally, due to the physical impairment); and handicap (the subjective significance one attributes to one's disability and the sense of deprivation and inferiority that stem from it, as influenced by cultural and social values and norms). This definition creates a conceptual continuity that ranges from the objective to the subjective (Arazi-Margalit et al., 2002) beginning with the measure of damage to the organ, continuing with the emotional distress and function loss and ending with the ramifications for general social function (Blich & Solomon, 2002). Thus, the experience of mastectomy as a handicap is derived from the perceived disparity between the social norms of femininity and a woman with no breasts.

This reference to mastectomy as disability emphasizes the role of reconstruction in coping with the removal of the breast and its repercussions. The meaning of reconstruction refers to a process of rebuilding that which was destroyed, according to its original design. That is to say, reconstruction is designed to reverse the state of disability. These findings are consistent with those of Crompvoets (2006), who calls attention to the multiplicity of meaning associated with reconstruction, presenting it as a restoration technique assumed to allow a full and emotional recovery from breast cancer turmoil.

Our findings emphasize the multiple and complex meanings associated to reconstruction, both by the medical staff and women themselves:

Reconstruction as a way to reduce psychosocial damage: Reconstruction prevents or reduces the psychological ramifications associated with having no breast, such as scarring, ugliness, a feeling of being flawed or disabled, damage to one’s self-image, and so forth. It may even give the patients some hope.

Reconstruction as a way to rebuild the breast to replace the one that has been removed: Reconstruction can create a breast that is not identical to the removed breast but can act as a substitute.

Reconstruction as a way to turn back the clock: Reconstruction reverses the mastectomy using breast implants.

Reconstruction as a way to recovery: Reconstruction serves to mask traces of the disease and facilitates the return to normal life as quickly as possible.

Although there is a measure of congruence between the four categories, there is also much dissimilarity. Thus, these categories constitute a theoretical framework for the examination of the different meanings attached to reconstruction. This wealth of meanings creates hope of healing, getting back to normalcy, reduction of psychological distress, and replacing that which was lost, especially when the breast is reconstructed immediately. By opting for an immediate reconstruction, women hoped to maximize these four meanings, especially those concerning dealing with the psychological aftermath of having no breast.

The women elected IBR during an emotionally charged, chaotic, and confusing situation of the diagnosis. They chose IBR as a way to cope with the frightening images and representations of being a woman with no breast. However, as our study shows, reality fell short of such expectations. The women woke up the day following the surgery and saw in their mirror a small, shapeless, and hollow bulge, or an organ that had the appearance and size of a breast, but which was not at all similar to the breast it was meant to replace, in its function and in most cases also in its appearance. All of the women experienced the reconstruction as a purely visual procedure, one that did not replace the real breast. Thus, they not only had to contend with a breast that did not appear as they had expected but also with their disillusionment. Contrary to other findings (McKean et al., 2013), the reconstructed breast only allowed them to look as they did but never to feel as before. They may look as though nothing had happened, but this is not how the women felt.

To sum, our study examined the experience of women undergoing IBR after mastectomy. Our findings contribute to a body of previous research (i.e., Crompvoets, 2006, 2012; Murray et al., 2015; Nissen et al., 2001; Wolf, 2004a, 2004b) that raise doubts concerning the benefits of reconstruction in general and immediate reconstruction in particular and support other qualitative studies that emphasize the disparity between the way in which immediate reconstruction is presented by physicians and the real experiences of women who undergo this procedure (White, 2002; Wilkins et al., 2000). This body of research, along with our study, adds to the growing criticism of IBR and its presentation as a vital procedure that cancels out the mastectomy and allows the patient to go back to normalcy. Our study emphasizes the complexity and multidimensional nature of the IBR process, and its wide-ranging repercussions as reported by women who have undergone this procedure.

Study Limitations

The study focused on the experience of IBR and included women of various ages and time elapsed since the operation. This diversity in a relatively small group of participants is one of the study’s limitations. As with most qualitative studies, we do not claim that our findings are generalizable to the broader population from which our participants are drawn. Further qualitative studies are needed in order to shed light on both the IBR decision-making process and its implications in coping with mastectomy.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Note

Author Biographies

Avital Gershfeld Litvin, PhD, is a medical psychologist, a lecturer at the Tel-Aviv Yaffo Academic College, Israel. At present she works as a medical psychologist at The Sheba Rehabilitation Hospital in Israel. Her main research and clinical interests are coping with breast cancer, loss and bereavement, disenfranchised grief.

Rebecca Jacoby, PhD, is a clinical and medical psychologist, an associate professor at the Tel-Aviv Yaffo Academic College, Israel. At present she is the chair of the Medical Psychology graduate program and editor of the medical psychology section of the Israel Journal of Psychotherapy: Dialogue. Her main research and clinical interests are Hope, Narrative Psychotherapy, Poetry and Doctor-Patient Communication. She is an editor of Between Stress and Hope: From a disease- centered to a health-centered perspective (Praeger, 2003).

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