In her photography series Intra-Venus, Hannah Wilke shows her body profoundly altered by a lymphoma. The US artist, who located the female body at the centre of her artistic expression, exploring the interconnections between feminism, femininity and sexuality, presents in these pictures a vivid and honest portrait of a sick woman. The series title is a wordplay on a way of administering medical treatments, including chemotherapy, and Venus, the pagan goddess of beauty. Many of the photographs depict Wilke with no hair, and her semi-naked body traversed by tubes and patches. These powerful images encourage the observer to question beauty standards through the lens of illness. Can a woman with cancer still be beautiful? And does conventional beauty still have any relevance in the face of mortality?

Wilke illustrated an experience common to many women who, after a cancer diagnosis, find themselves redefining their position in relation to beauty norms. The changes brought on by illness and treatments can profoundly alter their body and the relationship women have established with it over the years. While some changes may be expected, such as hair loss due to chemotherapy, others, like weight gain and hot flashes from hormone therapy, can come as a surprise. Women often learn to recognise and appreciate their post-diagnosis body with all its changes. Intra-Venus suggests that, after cancer, women, rather than abandoning the dominant norms of beauty, reposition themselves in relation to them, redefining the meaning of attractiveness and seduction. However, the physical and emotional metamorphoses that come with cancer are complex and marked by ambiguities, ambivalence and sometimes grief for the body and life they had before the disease.

This chapter attempts to map the rich and nuanced strategies through which women come to terms with their new bodies, in particular through an exploration of the changes affecting the breast, understandably the most iconic of the body parts when it comes to breast cancer. The breast and its metamorphoses are explored, paying attention to how the medical system influences patients’ individual perspectives. The objectives of medical professionals and patients only partially coincide, and their fulfilment is contingent on a medical system that can be rigid and offer only limited support.

In this chapter, I explore the multiple meanings and uses of the assemblages of post-mastectomy bodies. A breast reconstruction may include prostheses and the transplant of autologous tissue, but the reconstruction shows how bodies do not just ‘end at the skin, or include at best other beings encapsulated by skin’ (Haraway, 1985: 97). In the previous chapter, I focused on medical-bodily assemblages to indicate how changes in biomedicine, from the conceptualisation of a condition to innovations in treatment, are associated with the transformations of the disease itself and, consequently, with how patients experience the disease. Here, I focus more specifically on the bodily aspect of the medical-bodily assemblages that can be identified in the explicit reshaping of the body linked to breast cancer and its treatments. Body alterations, for example, through reconstructive surgery, make these assemblages tangible and visible. Moreover, when strong social norms, such as gender norms, target the body part concerned, bodily assemblages also reveal how these norms and expectations shape the body. ¹

The process of reconstruction involves negotiating with the medical system, grappling with the language of bodily integrity and exploring the practical uses of one's own body. By examining the different ways in which reconstructed bodies are assembled within their respective social and cultural contexts, we can go beyond the traditional feminist analyses of cosmetic and reconstructive practices, which often focus on resistance to or compliance with hegemonic ideas of normality and beauty.

What is gained and what is lost: or the aestheticisation of breast cancer

Breast cancer is strongly associated with the risk of losing the breast when a mastectomy, a surgical removal of the breast, is needed. The history of this operation is linked to the name of William Halsted, the US surgeon who, towards the end of the nineteenth century, implemented a meticulous technique known as radical mastectomy. Radical mastectomy involved the removal not only of the breasts but also of the pectoral muscles and the axillary contents (Lebovic, 2019). The surgery was highly debilitating, but removing a large part of the tissue around the tumour marginally reduced the risk of a local recurrence. For this reason, radical mastectomy remained in use until the 1960s (Lebovic, 2019). During the 1970s, a modified version of the radical mastectomy, in which the pectoral muscles are not removed, gradually replaced Halsted's surgery (Madden et al., 1972). Both radical mastectomy and modified mastectomy were based on the idea that breast cancer is a localised disease that, if left untreated, could extend to contiguous areas (Aronowitz, 2007). In the 1980s, in the US, modified mastectomy was the most widespread operation (Montini and Ruzek, 1989), but advances in surgery had meanwhile demonstrated the effectiveness of conservative surgery (lumpectomy, quadrantectomy), which does not include the total removal of the breast (Lerner, 2001 – who also notes how conservative surgeries gained acceptance among European surgeons at an earlier date than among those in the US). Canadian oncologist Vera Peters (1975) was the first to publish data from a retrospective study demonstrating the effectiveness of conservative surgery associated with radiotherapy (see Cowan, 2010). The clinical trials conducted by Bernard Fisher in the US (Fisher et al., 1985) and Umberto Veronesi in Italy (Veronesi et al., 1981) definitively demonstrated the validity of conservative surgery, which became the standard treatment for small tumours. According to Umberto Veronesi, the new surgical approach represents a paradigm shift in contemporary oncology, which, for the first time, commits to saving not only the patient's life but also her quality of life (Carlson, 2003). According to the Italian surgeon: ‘[T]he quadrantectomy caused an overturning in the history of cancer treatment, for it established at least three cornerstones on which modern oncology is founded: the importance of early diagnosis, the principle of minimum effective care, and the attention to the psychological dimension of the disease’ (Veronesi, 2012: 25).

As mentioned in Chapter 3, conservative surgery and early diagnosis of breast cancer appear strongly intertwined, both because the operation is performed to remove small tumours and because the fact that small tumours can be treated with conservative surgery could encourage women to check their breasts and undergo screening. As we will see later, conservative surgery techniques have been developed to offer women the best possible aesthetic results. ² However, before following the evolution of conservative oncological surgery, it is important to underline that mastectomy has not disappeared. On the contrary, there are indications of a resurgence of mastectomy. As we have seen in Chapter 3, it can be performed to treat in situ cancers and for genetically at-risk patients. A retrospective epidemiological study using data from the Kentucky Cancer Registry showed that mastectomy rates increased in the early 2000s after declining in the 1990s (Dragun et al., 2013). In the UK, mastectomy rates vary significantly from institution to institution. Research published in 2011 found that institutions reporting high mastectomy rates are associated with greater patient autonomy in decision making (Caldon et al., 2011). The centrality of mastectomy in the therapeutic landscape has led to the development of different breast reconstruction techniques, which can be divided into two groups. The first group includes techniques that use external materials to create the volume of the breast, such as a prosthesis filled with silicone or saline solution. The second group includes transplants of autologous tissue (fat or muscle) taken from the patient's back, abdomen or glutei.

Reconstruction is presented as the moment of restitution, when a woman regains, at least in part, what she lost to cancer: her breast. It has been historically contested among breast cancer activists (Lerner, 2006), with some, such as Rose Kushner, emphasising the importance of conservative surgery and access to reconstruction, and others, such as Audre Lorde (1980), criticising reconstruction as invisibilising the disease and its political implications. In France, in particular, I met both groups of patients promoting specific reconstructive techniques and others advocating non-reconstruction (Greco, 2016c). The post-mastectomy reconstruction, which generally follows the therapies, is considered the least stressful moment in the treatment pathway because the patient has completed the most difficult therapies, such as chemotherapy and radiotherapy. As Dr Gilles, a French plastic surgeon, stated: ‘the reconstruction is almost a moment of happiness’. This assertion, however, seems at odds with the description of reconstruction as ‘the obstacle course’, as it has been defined by several patients (Greco, 2020b). These two definitions are formulated from two different positions, with surgeons often emphasising the benefits of reconstruction. For example, another French surgeon, Dr Françoise, told me that patients who have undergone reconstruction have better survival times. She explained these data by stating that undergoing a reconstruction shows ‘a willingness to fight (c’est un facteur battant), [that is,] those who decide to have a reconstruction are also those who have the energy to do it, but they are also those who feel good because they have a reconstruction’. While some studies show a correlation between reconstruction and increased survival time, the main hypothesis is that the increased survival is attributable to patients undergoing reconstruction being more likely to have more economic resources (Bezhuly et al., 2009). Some of the surgeons whom I interviewed advanced another argument as an advantage of reconstructive surgery: the aesthetic improvement that can be obtained through the operation. The reconstruction becomes a moment when the norms underlying the canonical image of the female breast become explicit. In this regard, Dr Françoise said:

Dr Françoise was therefore explicit that reconstruction can be a gain in relation to the pre-diagnosis breast, even though recognising that this happens as part of a negative event (and that patients themselves are not likely to describe it as a gain). Franca gave an account of the conversation she had with her plastic surgeon, which is along the same lines:

Franca did not appreciate this way of describing the operation: not only did she consider the tone unsuited to the context, but she also disagreed that her natural breast required any change. Other patients had a more favourable opinion of the changes produced by the reconstruction. As Angeline, a French woman in her forties, told me:

For Angeline, breast reconstruction was the ‘carrot’ that allowed her to find a positive element in a difficult situation. The woman was satisfied with the result and considered her breasts ‘prettier than before’. She was among the patients who, in Dr Françoise's words, could gain something from reconstructive surgery. Angeline's experience demonstrates the importance that post-mastectomy reconstruction can have for many women and also shows the plurality of ways that they use to come to terms with and redefine their experience of illness (see also Chapter 6). Angeline's account reminds us that accessing surgical solutions that offer a good aesthetic result can improve the patient's quality of life. ³ Oncoplasty (see, e.g., Garrido et al., 2006) is an approach specifically aiming to apply cosmetic surgery techniques within an oncological context. The choice between mastectomy and conservative surgery depends on a number of factors, such as the size and location of the tumour and the size of the breast, which are also considered in relation to the anticipated aesthetic result (Cothier-Savey and Rimareix, 2008). Oncoplasty enhances the aesthetic results of a conservative approach making use of cosmetic surgery techniques. Garrido and colleagues (2006: 715) present it in these terms:

This description shows how the objectives of cosmetic surgery have been introduced in the oncological context along with the techniques (Greco, 2016d). In particular, the authors discuss how purely aesthetic characteristics of patients’ breasts should also be considered when they undergo breast cancer surgery, such as asymmetry, hypertrophy (excessively large breasts) and ptosis (sagging). This shows how deviations from a normative ideal of the breasts are medicalised along with cancer, aiming to bring both the cancerous breast and – often for reasons of symmetry – the contralateral healthy breast within this normative ideal. In recent years, a new approach called extreme oncoplasty (Silverstein et al., 2015) has been introduced to extend the conservative approach to cases that in the past would certainly have been treated with a mastectomy, that is, in patients with a tumour larger than five centimetres.

The institutional context of breast reconstruction

Surgical advances play a pivotal role in shaping breast cancer experiences; in this section, I focus on the institutional context in which these advances are implemented. In the UK, NICE guidelines suggest that, after a mastectomy, women should be offered both reconstruction options – immediate and delayed – ‘whether or not they are available locally’ (2018: 12), and they also emphasise the importance of informing women about the different surgical techniques available. However, the implementation of these guidelines may vary. A survey carried out in 2022 by Breast Cancer Now, ⁴ one of the leading British breast cancer charities, has shown that some patients are offered only one option, for example, a reconstruction with breast implants, because other types of intervention, such as free flap surgery, are not available locally. The report also highlights how, in some cases, the choices are restricted by the internal organisation of some medical institutions which, following a mastectomy, limit the time after which patients can request a reconstruction, or limit the number of operations that can be performed during a reconstruction, sometimes excluding the contralateral symmetrisation. As we will see in the next section, contralateral symmetrisation is an intervention on which women may have differing opinions. However, this operation can be experienced, as Angeline's case showed, as an integral part of the reconstruction process and necessary to obtain a whole image. Financial considerations are central to medical choices, however, and medical professionals are encouraged to analyse the financial impact of reconstruction in the medium term (see Atherton et al., 2011). Free flap surgeries are generally more expensive, as compared to the insertion of a prosthesis, but autologous reconstructions usually require less follow-up over the years, while in many cases the prostheses need to be replaced.

The financial question is also central in Italy, where a group of more than seventy breast surgeons discussed at the Italian Senate the difficulties that patients and medical professionals face in the case of breast reconstruction. In many Italian regions, immediate reconstruction is often not included among the surgical procedures that the regions reimburse to individual medical institutions. In some cases, the reconstruction operation is reimbursed only if performed after the mastectomy and identified as a separate surgical procedure (Moriconi, 2022). This can be difficult for women who would prefer immediate reconstruction, and it can be a financial issue for those institutions that decide to continue offering immediate reconstruction. Another factor to which the group of surgeons have drawn attention is that in several cases reconstruction operations carried out with microsurgical techniques, despite being longer and more complex, are reimbursed less than the insertion of prostheses. We have seen in Chapter 1 how the significant gap between the north and the south of the country marks the Italian institutional context. However, in the case of reimbursement practices for post-mastectomy reconstruction, we see an uneven situation with some regions, defined as virtuous, with more efficient reimbursement practices, and others less so, without any alignment across the traditional north–south axis.

In France, many of the patients whom I met told me they had undergone different treatments in different institutions, and many of the women with whom I spoke had reconstruction in private healthcare facilities and paid for it. The porous relationship between public and private healthcare that characterises France, and the fact that medical personnel, especially surgeons, often work in both public and private facilities, probably facilitate the movement of patients. For some patients, these operations carried out in the private sector are reimbursed through their medical insurance (see Chapter 1). Other women whom I met said they had paid for a procedure that should theoretically be guaranteed by the French health system (see Greco, 2015). Difficulties in accessing reconstruction increased during the COVID-19 pandemic, when elective surgeries ⁵ were paused in many European countries, including the three covered in this book. However, the pandemic highlighted an already existing phenomenon, as long waiting times often emerged as a problem in my fieldwork. Many patients in the UK, Italy and France have had to wait longer to access reconstructive surgery, which has often negatively impacted on their well-being and the ability to close a painful chapter in their lives. In France, during my fieldwork (and therefore before the pandemic), many patients mentioned long waiting times as one of the reasons for carrying out the reconstruction in a private facility. The concept of choice is dominant in the discourses surrounding breast reconstruction. However, this rapid excursus on the institutional context of post-mastectomy reconstruction shows how the surgical offer and the unequal distribution of such offers severely limit women's choices. In the three countries studied, only a minority of patients who undergo a mastectomy opt for surgical reconstruction. ⁶ Long waiting times, difficulty in accessing the technique deemed most appropriate, financial problems or communication difficulties with the medical staff are among the obstacles women face when they decide to pursue a breast reconstruction. The fieldwork also revealed women's different strategies to overcome these difficulties, mobilising a range of resources. From seeing multiple doctors and changing hospitals, to paying for the surgery, many of my interviewees overcame various obstacles to achieve a goal that was important to them. The reasons why some women wish to undergo post-mastectomy reconstruction are complex and involve different aspects of their lives, as we will see in the following sections.

Negotiating surgery and its aims

The availability of several reconstructive techniques paves the way for further forms of negotiation and compromise for patients, who have to take into account both the limitations and risks that each option presents and what the medical staff can offer. ⁷ Dominant beauty standards emphasise the appearance of the breast over the sensations, emotions and experiences attached to it. Similarly, cosmetic surgeons tend to consider operations successful in which the resulting breast is similar to a normative one (Greco, 2016d). However, women's relationships with their bodies and normative beauty ideas are diverse, multifaceted and often under-explored. In this section, I focus on the processes of negotiation that women have to go through with the medical culture and the materiality of the body that can resist attempts to modify it and turn reconstructive surgery into a failure.

Analysing these aspects allows us to capture better the complexity and ambiguity of breast reconstruction, a phase of the therapeutic pathway that can increase the difficulties of the disease. ⁸ Florence was in this situation. In her late thirties, she had a mastectomy followed by a latissimus dorsi flap, using muscle and skin from her upper back to reconstruct a breast volume. During the interview, Florence said that doing a reconstruction was not crucial to her and that she felt she was somewhat pushed into it during the medical consultation. She recognised that the cosmetic result of the reconstruction was excellent, but after some time a recurrence of cancer in the reconstructed breast necessitated its removal. The second mastectomy was very difficult for Florence, as she was left with back pain caused by the removal of a muscle for a reconstruction that had not been a priority for her.

Régine, a French woman in her late fifties at the time of the interview, had a similar negative experience. Unlike Florence, Régine wanted a breast reconstruction, but she was sceptical about the prostheses the surgeon inserted in her contralateral breast to improve the aesthetic result. A subsequent infection in the contralateral breast exacerbated the difficulty of Régine's post-surgery phase. During the interview, she said that one of the factors that made that period more difficult was her awareness that most of the difficulties were caused by this contralateral symmetrisation, about which Régine had never been fully convinced and which she felt the surgeon had never discussed adequately with her. Régine wanted a reconstruction in order to find bodily integrity, which was very important for her, not to conform her breast and body to a normative idea of beauty. However, that symmetrisation ultimately interfered with her desire to regain her strength and to leave the experience of the disease behind.

Franca also had problems with the contralateral operation, which left her with constant pain in her nipple. While she had a strong desire for a breast reconstruction, she said that the operation was not enough to bring back a sense of bodily integrity; moreover, after the cancer and the surgery, even the healthy breast was no longer a part of her body capable of giving her the feeling and erotic pleasure she experienced before the diagnosis.

Amélie, a French woman in late fifties, told me she had refused contralateral symmetrisation because she did not want to undergo a second procedure and a second anaesthesia. She also told me that while she was pleased with the aesthetic result, her surgeon was not, as he thought a symmetrisation would have improved the outcome. Such divergences of opinion between doctors and patients on what constitutes a good aesthetic result emerged in several interviews. Clothilde's experience, for example, was similar to Amélie's, as she described in negative terms her first encounter with a plastic surgeon who had not wanted to use silicone prostheses that would have increased the size of Clothilde's breasts, also operating on the healthy breast. For Clothilde, this imposition of such a radical change was ‘a lack of respect’, and she decided not to undergo the surgery and to delay the reconstruction, even though she wanted to have one. Clothilde consulted other surgeons, some in the private sector, and eventually met a private surgeon who performed a breast reconstruction without inserting any contralateral prosthesis. She described this surgeon as someone who listened to her and respected her body and her desire not to alter her healthy breast. Clothilde was not the only patient to consult several surgeons, and was not the only one who paid to undergo a reconstruction (see Chapter 1). For Clothilde, having to move into the private sector was not a problem, but she was aware that for many patients it might well have been a problem. The interconnection between private and public structures, particularly strong in the case of breast reconstruction, allowed several women to consult more doctors, as they could move between the two. However, some women had to take out loans or use personal savings to pay for reconstruction in the private sector. In some cases, women had to pay several times, for the first surgery and for follow-up interventions needed years later (cf. Greco, 2015).

The story of Freya, a British woman in her forties, shows the role of another instance of negotiation that goes beyond the relationship between surgeon and patient, that of multidisciplinary teams (MDTs). ⁹ Freya and her surgeon agreed to perform an autologous reconstruction with fat harvesting and uplift on the other side. However, the MDT rejected this option as too invasive and proposed a dorsal flap instead. Freya disagreed with the MDT's decision and instead trusted her surgeon's judgement (‘So when he came back to tell me that they didn't want to do it, I was really upset, I said “but to me, you are the person I chose, they're not the people that I know and I trust, and I believe in you”’). Ultimately Freya and her surgeon found a compromise by performing only one operation with a transplant of autologous fat tissue, which gave a satisfactory result.

The stories presented have a specific aspect of reconstruction in common, that is, contralateral symmetrisation, an operation involving a healthy breast, and for this reason its role raises several questions. In cosmetic surgery, conflicts between the aesthetic criteria of surgeons and those of patients are not uncommon. ¹⁰ It is, therefore, not surprising that episodes of negotiation and disagreement converge around this aspect, which, more than others, blurs the line between cosmetic and reconstructive surgery. The women whom I met did not always want a ‘better’ breast: often, they were trying to obtain a breast as close as possible to the one they had before the diagnosis. By refusing bigger implants or contralateral symmetrisation, they called into question the vision of the surgeons, which was often based on purely aesthetic criteria rather than on functional ones. The experiences of these women extended the semantic field of the term ‘conservative’. In medicine, ‘conservative’ is the surgery that, in opposition to mastectomy, makes it possible to preserve the breast. For some patients, preserving the body's integrity meant accepting the reconstruction, but refusing operations on the healthy breast, even if further surgeries could offer results closer to the aesthetic norm. Some patients also wanted to conserve their time and energy, avoiding the fatigue and stress of additional surgeries that they considered unnecessary. Complications related to contralateral symmetrisation were experienced as a further loss. At the same time, for some patients, like Angeline, contralateral symmetrisation was an indispensable part of finding themselves in their own bodies. As she pointed out, having better breasts is also a way to accept the experience of breast cancer.

The variety of experiences presented here shows that multiple factors can influence patients’ decisions and redefine the centrality of the aesthetic result emphasised by cosmetic surgery. Furthermore, in exploring the reasons that pushed women to carry out reconstruction, we discover that, even when aesthetic reasons were present, they were also linked to other elements guiding the women's choices. Colette, a French woman diagnosed with breast cancer shortly before turning forty, said: ‘The fact of having our breasts removed, in whole or in part, represents an attack on the mother and the woman, the [female] image seen through the eyes of others, seen through the eyes of the society.’ This quote illustrates the complex relationship that, if not the totality, at least a significant portion of women have with the role that different social spheres attribute to the female breast (see also Manderson, 2011). However, it would be incorrect to consider reconstructive surgery only as a way to conform passively to normative beauty ideals.

The choice to undergo a reconstructive operation was, in many cases, the result of complex, contextual and provisional negotiations that women engaged between their own body, their desires and the expectations of their family, their children, their partners ¹¹ and society more generally. As we have seen, the outcome of reconstructive surgery is not always positive, and the risk of complications is high. The women whom I interviewed were generally aware of the risks and limitations, but, for many, these were not enough to deter them from undergoing reconstructive surgery. The willingness to conform to normative aesthetic ideals, while occasionally present, was just a tile in the more complex mosaic of choices and factors guiding the actions of these patients. Among these was the need to do everything possible to stem the effects of the disease on their lives.

Sally, a British woman diagnosed in her thirties, told me that her surgeon did not give her an option for a reconstruction, which she felt was essential for her at that moment of her life. She added: ‘As a thirty-seven-year-old woman, I felt that I wanted [a] choice for whatever reconstruction, and he said “mastectomy” and that was it. So he did not give me the choice of reconstruction and that's what I wanted at the time.’

Sally was not the only patient to emphasise the importance of reconstruction as a possibility that helps women to better face the prospect of a mastectomy. At the time of her diagnosis, Colette was a young woman with small children, a husband, a family and a job she liked. She told me that she was ‘prepared for a certain number of things’ at the moment of the diagnosis. Her words suggest that she had already considered the possibility of losing her breast, and also the possibility of undergoing a reconstruction. She had a reconstruction through the insertion of a silicone prosthesis, but while the reconstruction was initially successful, Colette had to have the prosthesis removed because complications appeared shortly after the surgery. She described the experience in these terms:

Colette knew her options, and also that many women had decided against reconstruction. Immediately after her diagnosis, she was determined to undergo reconstruction; however, the failed surgery (l’échec) undermined her resolution, and she hesitated whether to attempt a second surgery or to remain asymmetrical. She told herself that she was ‘ready to stay with one breast’, but the choice was not simple. She felt too young to stay with only one breast, and the figure of her husband emerged implicitly in her narrative (‘too bad for my husband’). We do not know whether the fact that she was in a heterosexual relationship might have steered her towards surgical reconstruction. During the interview, Colette often said that this second reconstruction was a way to ‘go for broke’ (essayer le tout pour tout) before giving up.

Béatrice's experience, although different, echoes Colette's complex pathway toward a second reconstruction. At the time of the interview, Béatrice, a French woman, was in her sixties and had been affected twice by breast cancer. The first time she was only thirty years old, and in that case it was possible to perform conservative surgery. A few years later, a recurrence in the same breast was diagnosed, and a mastectomy was necessary. For more than ten years, Béatrice lived in an asymmetrical body and was not interested in a reconstruction. However, with the passing of time, she changed her mind. Béatrice told me that cancer was not the only problem she had faced; she had had marital problems, resulting in a divorce. After the end of her marriage, a new partner entered Béatrice's life, and she described the new relationship as happy and fulfilling. After meeting her new partner, she decided to undergo a reconstruction. Unfortunately, an infection forced the surgeon to re-operate on Béatrice to remove the prosthesis a few days after the operation. When asked about this decision, Béatrice offered a lengthy answer which started by describing some details of her childhood. She told me about her complicated relationship with her parents, because of which she felt a need for appreciation and recognition. During childhood, Béatrice was a diligent student and sought, as she could, to make her parents proud of her. But she did not receive the appreciation she needed until several years later, as an adult. After talking at length about her parents, Béatrice added, ‘when I met my [second partner], he did not ask me [to do a reconstruction] because he accepted me as I was. [I did it] for me and for him too, without him asking me … [But] I wanted to have two breasts.’

When it comes to reconstruction, technique and aesthetic results are not the only important elements. For many women, the time and the context of the operation can be relevant, as Celeste, a southern Italian woman in her sixties, shows. She had undergone a mastectomy a few years before and told me that family members and medical personnel had tried to convince her to have a reconstruction. She thus decided to book an operation in Milan, a city far from her region of residence, but then cancelled it at the last minute because she was worried at the idea of having surgery far from home. However, Celeste did agree, sometime later, to have a reconstruction in a hospital near her home town.

For Sally, Colette, Béatrice and Celeste, the post-mastectomy reconstruction was an attempt to find a balance in their lives by attending to their bodies. The choice to perform a reconstruction can result from opposing forces, and the body materially produced by reconstructive surgery – often different from what is meant by a ‘normal body’ – incorporates the tensions and contradictions that women might be experiencing. Crompvoets defines reconstruction as ‘the last bastion of hope’ (Crompvoets, 2006: 90), the last hope that women have to regain a body conforming to the current standard of beauty. According to Crompvoets, it is only after the reconstruction that women begin to articulate a new self-image and accept the changes brought by the disease. The women whom I met had realistic expectations regarding the aesthetic outcome of their surgery, and they were aware that, from an aesthetic point of view, a reconstructed breast would be different from a real one, but often what women were trying to obtain was not just a two-breasted body but closure by doing everything in their power to limit the impact of the disease on their lives. However, the surgery can also be fraught with emotional tension, as it represents the last opportunity to take control of their changing bodies.

Uses of the post-reconstruction body

Élodie, a French woman who was almost sixty years old at the time of the interview, had discovered her first cancer at thirty-nine years old. At the time, she underwent a conservative intervention, followed by radiotherapy. Her surgeon advised her to contact a plastic surgeon to consider a partial reconstruction of the operated breast, but Élodie refused, as the altered image of her breast did not bother her or her husband. Several years later, Élodie discovered a recurrence on the same breast, and a mastectomy was necessary this time. About this second mastectomy, she said:

For Élodie, the aesthetic sequelae of the first operation were not significant enough to begin reconstruction, but the situation changed after a mastectomy. This operation broke her balance, and she could no longer recognise herself in her new body. What does it mean to no longer recognise yourself in your own body? In this expression, there is, of course, the idea of not recognising yourself in the image that the mirror reflects to you. However, the interviews show that this expression can also refer to the fact that a different body reduces the range of activities and experiences that women can have. Several interviewees highlighted that they were aware of the difference between a reconstructed breast and a natural one ¹² and knew that a reconstructed breast does not replace the sensations of the natural breast (see also Manderson, 2011). Discussing a different surgery – oesophageal reconstruction – Mitchell and Snyder (2016) also point out that a surgical assemblage normally does not reconstitute the previous tissue, and therefore cannot really restore the ‘before’ state. But for many of the patients whom I met, the reconstruction was a pragmatic choice which made it possible to extend the range of uses of the body and give them greater freedom. As Clothilde told me: ‘Even if it's totally fake, now I call it the “tit-toc” … I think it's more pleasant for everyone, I tell myself there's no longer that side devastated, and then I can dress as I want, freedom too, so it's a social breast.’ And the experience of Sandrine, a French woman in her forties, pointed in the same direction:

Sandrine did not question that her body was now different, but with the prosthesis, she could easily hide this difference and continue to play sports. For Sandrine, this was very important; in fact, immediately after the procedure she was ‘completely obsessed’ with the risk of developing lymphedema and thus losing the mobility of her arm. Fortunately, the recovery was perfect and she ‘didn't feel at all that it affected [her] daily life’. Other women had a pragmatic vision of the reconstruction and have underlined how a reconstructed breast can make some everyday activities, such as attending a public gym class or going to the beach, more manageable than an external prosthesis would. As Clothilde reminds us, the reconstructed breast is a ‘social breast’, because it restores a socially accepted appearance to support the ‘social gaze’, that is, the normalising set of expectations that society puts upon women's bodies. Film theorist Laura Mulvey introduced the concept of male gaze (1975) to indicate how female characters in films are seen through the perspective of the men, who can be both male spectators and other male characters in the fiction. Since then, the male gaze has been used to indicate the pervasive expectations that men can have regarding women's bodies. However, the social gaze to which women refer is not just male; many women underline the role of female family members and friends in orienting their decision to pursue a normalised, two-breasted body, while others, like Sandrine, found comfort in female friendship. Reconstruction could also be a means to free oneself from this social gaze and the critiques that a nonconforming body can attract. In this sense, breast reconstruction can be simultaneously an exercise of agency on the woman's part and an acknowledgement of the oppression of aesthetic norms (Gagné and McGaughey, 2002). In this oscillation between agency and oppression, women can decide to select and assemble the functions that a reconstructed breast can have.

This allows us to understand why many women decided to reconstruct just the volume but not the nipple, or not to undergo symmetrisation, as they considered these details superfluous for the uses for which the new breast was intended. This can also help us to understand why many women could be simultaneously satisfied with their decision to undergo reconstructive surgery while considering the aesthetic result imperfect.

However, the partial aesthetic results was sometimes enough to limit the range of social uses of the reconstructed body. This was the case for Franca, who, during the interview, said that with her reconstructed breast she felt comfortable enough to wear a bathing suit but could not appear naked in front of other women when she was, for example, in the gym. If, for Sandrine, Clothilde and other women I encountered, reconstruction was sufficient to put into action a process of passing and gave them greater freedom than an external prosthesis, this was not the case for Franca. Reconstruction was not in itself sufficient for her to regain the full use of the body; what was needed was a negotiation on her part to find a balance between the pre-mastectomy body and the post-reconstruction body. However, negotiation processes do not happen in a vacuum but in different social settings. Several research projects have shown that, in Italy, women are exposed to sexualised messages (Valtorta et al., 2016) and may be more at risk of internalising the idea that their self-worth is linked to their image (Moscatelli et al., 2021). In this context, pressures to conform to unattainable and elusive beauty standards can make it more difficult for women with breast cancer to accept their post-diagnosis body.

While it is essential to acknowledge local variations in the pressure that normalising aesthetic norms have on women, it is also important to recognise that virtually every woman who receives a breast cancer diagnosis has to ‘confront, in rapid succession, the dangers of the disease itself and […] subtle articulations of society's distaste for her “non-normalised” body […]. What resources are available for resisting the deep shame inscribed in this series of encounters?’ (Fitts, 1999: 8). Among the individual and personal resources available, Sandrine, for example, in her journey of acceptance, found the support of other women, particularly other women with a different appearance. In the interview, she recalled: ‘this summer, I went to Norway with my husband and other people I didn't know, and in the group, there was a girl who was badly burned, so my story was nothing compared to hers. And suddenly, we both found ourselves showering and laughing in a token-operated shower.’ Meeting a disabled woman allowed her to put into perspective not only her own difference but also the strict norms limiting women's bodies. Sandrine had the opportunity to deconstruct and reject what Fitts calls ‘society's distaste for [a] “non-normalised” body’. However, other women, such as Franca, for example, did not have the same opportunity and adapted to living in a body that they considered limited.

These experiences demonstrate the range of possibilities as well as the limits of the reconstructed body and the bodily assemblage achieved through surgery. They also emphasise the bodily assemblage work that women do with their bodies, the disease and the socio-cultural context in which they live. Women negotiate the meaning of the reconstructed breast for themselves and for others. ¹³ This assemblage work produced a provisional and negotiated body, the acceptance of which is contextual and often needs further renegotiations when circumstances change. Moreover, this work is done not only by those who have undergone a post-mastectomy reconstruction but also by women who live in an asymmetric body, as we will see in the next section.

Living in an asymmetric body

A surgical reconstruction is not the only option, as women can decide not to carry out any reconstruction, and to live in an asymmetrical body. ¹⁴ And, as we have seen, most women who undergo a mastectomy do live in asymmetrical bodies. Many medical professionals whom I met said that women ‘choose’ not to undergo a reconstruction; however, in many cases, the rhetoric of choice is insufficient to capture the nuanced experiences of women living with an asymmetric body. In this regard, Marie, a French woman in her early fifties who lived with an asymmetrical body as a result of two breast cancer diagnoses, told me that she found the notion of choice inadequate to describe her situation. ‘If I had a choice,’ said Marie, ‘I would have chosen not to have cancer.’ But the rejection of the notion of choice goes beyond the understandable rejection of disease, and Marie detailed the stages through which she had accepted her asymmetrical body:

I decided to include this long excerpt from the interview with Marie in full because it perfectly illustrates the different and difficult phases she lived through, and through which she learned to accept her new body. But Marie was also extremely clear that living in an asymmetric body was not a choice but, rather, the result of a complex process of coming to terms with the disease at different stages of recovery. She did not reject a reconstruction based on an explicit opposition to female beauty norms. Indeed, she wanted to undergo a reconstruction, but the operation was postponed, first because it was medically not possible, then because of Marie's personal and professional commitments. Eventually, a reconstruction was simply no longer necessary, as she had learned to accept her new body and felt comfortable in it. Still, she was nonetheless explicit in rejecting the simplistic rhetoric of choice: Marie highlighted that, while waiting for the right moment to undergo a reconstruction, she did not put her social, professional and even sentimental life on hold, which continued in an asymmetric body, until she realised that she no longer ‘needed’ a reconstruction in order to feel whole again.

Analysing women's experiences through deconstruction of the rhetoric of choice allows us to capture the complexity of living in a one-breasted body, thus helping us to understand how women's bodies are (re)defined and (re)shaped in daily interactions. In many cases, the post-mastectomy asymmetric body is in transition, fluctuating among changes caused by the different treatments women undergo. As Marie mentioned, it is often not possible to do a reconstruction immediately after a mastectomy, because patients are receiving other treatments such as chemotherapy, and especially radiation therapy, which can alter the outcome of the reconstructive operation. But the asymmetric body can be fluid because women can decide whether and when they want to wear an external prosthesis simulating a two-breasted appearance. ¹⁵ An external prosthesis is an ambiguous object: it normalises the body without permanently erasing the signs of the disease. However, the normalisation that it offers, even if temporary, can be a problem. Brigitte decided to abandon the prosthesis so as to fully accept her asymmetric body: ‘I gave up the prosthesis, and I started a work of acceptance of asymmetry. By giving up the prosthesis, I started to accept that I had an asymmetry, that my body was different and that I should start living with this different body.’ For many women, the device offered the opportunity to keep away unwanted stares and comments. This was the case for Lucrèce, a French woman in her forties at the time of the interview who did not undergo reconstruction. She said: ‘breast was not my thing (le sein n’était pas mon truc). I was not particularly attached to my breast, I put on a low-cut [dress], but that was it. I didn't spend all my time showcasing my breast.’ Lucrèce highlighted how her breast had a limited role in defining herself and added that, after the mastectomy, she did not find it difficult to look at her new body in the mirror:

The mastectomy did not alter the perception of her body as ‘whole’, and she used a prosthesis only to adapt her body to the gaze of strangers, because for her family the asymmetry was not a problem. Justine was another French woman, in her fifties at the time of the interview, living with an asymmetrical body. When I asked her if she had considered having a reconstruction, she told me that the medical staff had mentioned it but did not think she needed a breast reconstruction. When Lucrèce wore an external prosthesis, she did so for other people because she did not want to make them uncomfortable by showing a different body, but also for herself because the appearance of a conventional body could be a protection from the judgement of others. Lucrèce was not the only interviewee to reluctantly normalise her body. Justine told me that the prosthesis was uncomfortable and that she initially avoided wearing it. Her asymmetry was thus apparent, and she noticed that sometimes her colleagues cast critical glances at her body. She could tolerate the attitude of her colleagues; however, she told me that she did start to wear an external prosthesis after receiving a comment from her daughter, who invited her to hide the asymmetry.

Asymmetry distanced women from traditional standards of beauty and desirability and, in some cases, the interviewees tried to use this distance to their advantage, for example, to escape from explicit or implicit gender injunctions. This was the case for Apollonia, a woman from southern Italy who was seventy years old at the time of the interview and had undergone a mastectomy several years earlier. Apollonia hid her asymmetry by wearing a prosthesis, but from a personal point of view her asymmetry was not a problem. She told me that after her husband's death she had sometimes ‘instrumentally’ used the fact of having only one breast to fend off unwelcome suitors. Using her physical difference to deter the men around her allowed her to avoid unwelcome advances without necessarily being hostile. She could even pretend to protect men from her ‘abnormal’ body while actually aiming to protect her freedom as an adult woman who did not want to remarry.

While the experience of living in an asymmetrical body did not emerge in my British fieldwork, my results from France and Italy show interesting overlaps with previous research with younger cancer patients living in the UK. These studies have shown that women did not perceive their non-reconstructed bodies negatively and preferred not to undergo reconstruction so as to avoid unnecessary cosmetic surgery. Moreover, support from family and friends was central in the UK context as it was in the Italian and French ones (Holland et al., 2016; Archer et al., 2018). An important element emerging from the experiences of women who did not undergo a reconstruction is the lack of social awareness of asymmetric bodies. Many women, for example, have mentioned their difficulties in finding clothes that can adapt to an asymmetrical body. This is unfortunately not surprising, as the discrimination of the fashion industry against women whose body does not conform to stringent aesthetic norms is well known – for example, this has been explored in relation to women whose bodies are considered ‘plus-sized’ (e.g., Bishop et al., 2018). For women with one breast, it is possible to buy bras with a pocket to insert an external prosthesis, and charities and patient support groups can offer advice on how to adapt mainstream clothes to an asymmetric body, ¹⁶ but it is much more difficult to find clothes or bras designed for an asymmetric body. The assumption is that women with one breast do not want to make their difference visible to others. Some women adapt to this situation not only by combining clothes and fashion items, but by using their modified bodies as an opportunity to express and negotiate personal ideas of gender and femininity (cf. La et al., 2019). However, what emerges from women's experiences is society's lack of acceptance of the asymmetrical body. This can be another reason that makes the integration of asymmetry into women's lives an always partial process: it is easier to be asymmetrical in some situations than in others. But through these processes of assemblage, women stretch semantic and social boundaries to create new spaces for different bodies beyond the ideas of normality and beauty.

Conclusion

The experience of breast cancer can lead to significant changes in a woman's body, with the loss or alteration of the breast being one of the most challenging aspects of the disease. Reconstructing the breast involves combining different materials, such as silicone or autologous tissues. However, the process is often a negotiation between patients and the medical system, based on the resources available to the patient. In France, patients can use private healthcare, but this may exclude those with fewer resources. In the UK, reconstruction is generally done in the public sector, but intermediate regulatory instances (such as MDTs) may insert an additional level of negotiation in addition to the negotiation with the surgeons.

Moreover, the gradual process of aestheticisation of oncology seems to establish rhetorical and practical links between oncological and cosmetic surgery so as to justify the extension of cosmetic surgery techniques to the treatment of cancer. The patients whom I met shared only partially this emphasis on the aesthetic outcome of the surgery because, for them, the meanings and motivations of reconstruction were multiple and would go beyond just having a better breast.

The fact that beauty standards are not a priority for women does not mean they can dismiss them altogether, as women still need to navigate expectations to adhere to those standards. In daily life, women navigate these expectations by constructing different meanings and values for their bodies through their own bodily assemblage processes. Their homes, the doctor's surgery, the gym, the swimming pool or the beach are places where their bodies take on various roles and are perceived differently, contributing to different perceptions of wholeness and integrity. Through the reconstruction, women rearrange the uses of their bodies and individual and social values around the female body according to their personal hierarchies of what matters to them. Certainly, they have to take into account the materiality of their bodies, including the effects of disease and surgical transformations.

If surgeons wanted to reconstruct a beautiful breast, the women I met wanted to recreate not only a body that could be considered beautiful and natural but also a body in which to live a life as close as possible to their pre-cancer life. Some of my interviewees decided to undergo reconstruction after having lived in an asymmetrical body for a few months or a few years. For many women, a reconstruction had practical purposes: it was easier to find clothes that fit a double-breasted body, and if they went to the beach or the gym, a reconstructed breast, although different from a natural one, could hide their experience of the disease.

They did not want to draw attention at the seaside or in the street, while others mentioned that they did not want to shock or embarrass the people around them by disclosing their asymmetry. The attention and care towards other's people reactions once again reveal the hegemony of the two-breasted image. However, hiding the asymmetry from others also means not having to reveal the pain and the trauma of breast cancer: a breast reconstruction can offer a sense of control over the narrative of the disease and therefore contribute to the patient's biographical assemblage. For this, a partial reconstruction may be sufficient. In particular, most of those whom I met and who did undergo a reconstruction have said they did not pursue a nipple reconstruction because this step was considered unnecessary. Creating a volume, which avoided the hassle of inserting the external prosthesis, was sufficient. The desire to find, through either surgery or prostheses, a life similar to the pre-illness one is also strongly influenced by ideas about how a female body should be. A double-breasted silhouette corresponds not only to dominant aesthetic standards but also to social and moral norms. It allows for immediate gender identification and reassures not only the patients, or at least some of them, but mainly those who move around them – family members, colleagues or perfect strangers. Breast reconstructive surgery re-establishes a gendered order that is still dominant today. And it is precisely this social reassurance inherent in the two-breasted image that some women want to undermine. This becomes more evident in the use of the asymmetric body.

The asymmetry is a fluid situation that can be hidden on some occasions – when women are with strangers – and revealed in others – with their partner. However, some women can use their dissident bodies to negotiate their place in society and reject normative female roles, as in the case of Apollonia. Women living in a post-diagnosis body replace one-dimensional beauty standards with visions that include the variety of uses of the body. These visions bring to the surface the flexible and nuanced relationship that women have with their bodies, which emphasis on the adherence to normative beauty standards cannot capture.

In her analysis of Intra-Venus, Julia Skelly (2007) underlines how the series of photographs is an example of fragmented femininity. The fragments of femininity that Wilke evokes are part of the everyday experiences of many women living in a post-mastectomy body. This chapter has been an attempt to show how women can use these fragments to recompose richer and deeper images of the self. In the next chapter, I will discuss another example of recomposition, examining how women seek balance amid the uncertainty of breast cancer.