U.S. News

05.18.13

Angelina Jolie’s Mastectomy: The Brutal Truth Behind the Operations

From severed blood vessels to painful scars, doctors reveal what’s really involved in a double mastectomy. By Lizzie Crocker.

There's nothing sexy about a double mastectomy. A day after Angelina Jolie announced she'd had one, her doctor revealed a more detailed account about the actress's operations, including a painful "nipple delay" procedure. So far, it seems, Jolie is recovering well, and her nipples are intact. But it wasn't—and isn't going to be—easy.

We spoke with doctors about the brutal reality of these procedures, and the questions that linger even after a success is pronounced.

What exactly does a “nipple delay” entail?

Two weeks before getting her mastectomies in mid-February, Jolie underwent a nipple delay procedure—a complicated step in a nipple-sparing mastectomy that involves removing a small amount of tissue from beneath the nipple to ensure that it isn’t malignant (if it was, keeping the nipple would, of course, be a dangerous bet). Some blood vessels are severed in removing that tissue, so that the nipple becomes accustomed to getting a majority of its blood supply from the surrounding skin.

The nipple delay is as complex as it sounds, but removing that small bit of tissue can help the nipple survive a mastectomy.

“It reduces the risk of having the nipple slowly die, in which case it would turn black and have to be removed,” says Dr. Joshua Levine, chief of surgical services at the New York Center for the Advancement of Breast Reconstruction. According to Levine, the nipple either dies or survives within two or three days of the procedure.

What are the odds that the “nipple delay” will be successful?

There are no known figures when it comes to success of nipple delays, according to Levine. But chances of a successful surgery increase if the breast surgeon has had considerable experience with the procedure.

Jolie’s doctor has been incorporating nipple delays in her practice since 2008 and claims nipple loss in her patients has decreased to 2 percent. “In Angelina’s case, she judged it worth taking this extra step of caution,” wrote Jolie’s doctor, Dr. Kristie Funk, in a blog post on the Pink Lotus Breast Center’s website

But for women with larger breasts, nipple delays are rarely performed, according to Levine.

“In a large breast, the nipple can be 40 centimeters away from the sternum, which is a long way for blood to travel,” said Levine. Without adequate blood supply, the nipple is much more likely to die.

Does preserving the nipple also preserve sensation on and around it?

Nipples may remain intact during implant mastectomies, but they don’t retain nerve endings.

In other words, they’re still there, but the only function they serve is cosmetic.

“These nipples don’t stand up when it’s cold and they don’t respond to arousal,” says Dr. Judy Garber, the director of the Center for Genetics and Prevention at the Dana Farber Cancer Institute in Boston. “Losing all feeling in your breasts is a big trade-off for a lot of women. Many with a faulty version of either the BRCA1 or BRCA2 gene won’t get a mastectomy no matter what you tell them.”

For women with larger breasts, nipple delays are rarely performed.

Jolie could have chosen surgery known as the TRAM flap that involves using the patient’s own body tissue rather than silicone to reconstruct the breast, significantly increasing the odds of retaining sensation.

“When you use your own body tissue, nerves can actually grow into the breast,” says Levine.

What’s more, surgeons can create a “youthful, beautiful breast” when using living body tissue, whether it comes out of the thigh or the buttocks.

So why do so many more women opt for silicone implants?

The TRAM flap requires more surgeries and a significantly longer recovery period, says Levine, who recommends that his patients take a month off of work following the surgery. But he insists the long-term result is better. “The look like breasts, they feel like breasts, and they behave like breasts.” 

What are the odds that Jolie’s breasts will look “natural” post-surgery?

It’s a question that Jolie only vaguely referenced in her article.

With characteristic candor, she admitted that “the results can be beautiful” and that she doesn’t feel “any less of a woman” after having her breasts removed.

For a woman who has built much of her career on being a sex symbol, the fact that she was willing to lose a part of her body that is most closely linked to female sexuality for the sake of her health says a lot about her priorities. That she still feels fully feminine speaks to the success of her surgery.

Jolie’s doctor said her body type was “best suited to an implant reconstruction with allograft,” or teardrop-shaped silicone implants in addition to synthetic materials (the allograft) that make the breast look more natural.

One of the benefits of getting implant reconstruction is that the new silicone breast doesn’t age as much as a natural breast. But of course there can be drawbacks.

“Sometimes little ripples will develop in the silicone which can lead to further surgeries,” says Garber. Another potential side effect is what’s known as a contraction, wherein the silicone implant changes shape. Garber also notes that for many women, breast reconstruction involves a number of small, follow-up surgeries—something that didn’t come across in Jolie’s piece.

Jolie also chose to have the mastectomy incision underneath the breast in the fold that lays against the ribcage, known as an inframammary incision in medical speak. That type of incision is rarely performed on large breasts, according to Levine. But for small breasts, it’s arguably the best cosmetic option. He notes that the scar also fades over time.

“In terms of the way they look, these are breasts that most people would be very hard pressed to recognize as reconstructions,” says Levine.

And while Jolie seemingly cares little about the cosmetic effects of the surgery, Levine says she could likely pose nude in a year and a half, after the scars fade, and most people wouldn’t even know she’d had a double mastectomy.