Pink October and the fight against breast cancer: "In breast reconstruction, France is a poor performer compared to other countries." Interview with Isabelle Sarfati, cosmetic surgeon

As every year at this time for 39 years, the operation Pink October is renewed for a month, with one objective: to raise awareness among women about breast cancer and encourage them to get screened. Breast cancer is in fact the leading cause of cancer death in women, and the initiatives of Pink October are an opportunity to remind people of the potential seriousness of this disease. A disease that highlights another problem: that of breast reconstruction.

Every year in France, there are 49 new cases of breast cancer, forcing more than 000 women to undergo a mastectomy. Unfortunately, only 20 to 000 of them have their breasts reconstructed: either by personal choice or, more often, due to a lack of means. In terms of breast reconstruction, it must be said that France is a rather poor performer compared to other countries, as deplored by Isabelle Sarfati, a plastic surgeon for 30 years. Now working at the Institut du Sein, located in Paris, this renowned plastic surgeon gave us an interview to talk about her profession and the evolution of morals over the past three decades. A fascinating interview in which Isabelle Sarfati tells us about her patients (and patients!) and the many cases she treats: breast augmentations and reductions, reconstructions, operations on transsexuals, with women wanting to become men and vice versa… The daily life of this cosmetic surgeon, at once astonishing, incredible and moving, shows us to what extent her profession can change or save lives. A moving testimony to discover…

Jérôme Goulon: Hello Isabelle. How long have you been a surgeon?
Dr Isabelle Sarfati: I have been a specialist in breast surgery for 30 years. It is important to note, to fully understand my profession, that there are several registers in breast plastic surgery. 

Which ?
There is of course cosmetic surgery, with breast augmentations or reductions, as well as sagging and lifting breasts. And then reconstructive surgery: malformations and reconstructions after breast cancer. 

Breast reconstruction only concerns women with cancer?
Breast malformations are quite common, with for example young girls having tuberous breasts. This is a congenital malformation. Young girls, at the time of puberty, see breasts appear which have a very strange shape. It's very common, but before, they didn't dare talk about it or show it to their parents. They didn't really know what they had and they were extremely self-conscious. Now that has changed, because they find these breasts on the Internet. They recognize their malformation and can find out more. They understand that it can be corrected and that they can be operated on quite easily. 

I imagine that in 30 years, cosmetic surgery has evolved a lot...
Yes. Two things have changed. First, there is greater diversity. In the 1980s and 1990s, everyone wanted to look like the same model. All the girls wanted to be slim with long legs and busty breasts. Today, beauty standards and muses are diverse. There is Kim Kardashian, Beyoncé, Kate Moss, androgynes… There is a diversity of identification. People feel better about themselves and their style. 

And the second thing that has changed over the years?
Today, many women just want to feel good, without modesty or complexes. Virginie Despentes said a phrase that I find very funny: “I am modest because of my complex”. Today, people want to be good, just to embrace who they are. 

Have you ever said no to a patient?
It's not very common, but it happens. What pushes me to refuse is when I know that I will not be doing the person a favor, that they will not be happy with the result, and that instead of being satisfied with their breasts, they will be dissatisfied of the surgery, therefore of me. 

You said that some women want to increase the size of their breasts while others want to reduce it. What is the distribution?
This will surprise you, but now it's 50/50, whereas 20 years ago, I made more increases than reductions

What is the average age of your patients?
I see everything. My patients are aged from 14 to 90 years old… 

14 year old girls? Isn't that too young?
Very young patients generally come for malformations and very large hypertrophies. When a 14 year old girl has breasts that reach her navel or weigh 1,5 kg each, there is no point in waiting for them to shrink, because they are not going to shrink. So yes, we can operate on certain breast malformations and hypertrophies at a very young age.

Do the women who come to see you following cancer represent a large proportion of your patients?
About 50%…

Only 20% or 30% of women who have had cancer undergo breast reconstruction. This is little… 
It is very weak indeed. In breast reconstruction, France is a poor student compared to other countries. Afterwards, there are two groups of women who do not have reconstruction. There are women who do not want reconstruction, because they feel that they are comfortable in their own skin and that they have seen enough doctors during their cancer. They therefore no longer want to hear about surgery. And then there are the women who cannot find anyone to reconstruct them or who cannot afford to pay excess fees for private reconstruction.

Is it a question of money?
Not only that. Breast reconstructors are often found in large cities. There are not plastic surgeons everywhere. 

Breast reconstruction is not covered by social security? 
This is covered 100%, but on the basis of the Health Insurance rate, which does not reflect the real cost. For breast reconstruction, the social security pays around 225 euros for an intervention of around two hours and 3 weeks of post-operative monitoring. There is therefore a significant out-of-pocket cost for patients.

How much does breast reconstruction cost?
In the private sector, breast reconstruction costs between 2 and 000 euros, knowing that there are often 4 interventions and a reconstruction of the areola and the nipple.

And in the audience?
In public service, it's free. In hospitals or in cancer centers, when breast reconstruction is done, it is fully covered by social security and there is no out-of-pocket cost. The problem is that there is a traffic jam. The waiting time can range from 6 months to a year and it has gotten much worse since Covid.

What would you like to say to women who do not want to wait for a place to become available in the public sector and who cannot afford to go to the private sector?
There's not much to say. We are currently working on the creation of a foundation where we would collect money from donors in order to take charge of reconstructions in the private sector...

Women go abroad to pay less. What are the pitfalls to avoid ?
You are talking about cosmetic surgery. The problem with surgical tourism is not so much the level of the plastic surgeons, it is mainly the follow-up. Postoperative follow-up is at least a month or two. Complications can occur after 15 days, 3 weeks, a month, or simply dissatisfaction with the result. And being away from your surgeon post-op is damaging. 

Other subject. You also operate on women who want to become men. Tell us about that…
There are two types of surgery on transsexuals. When it is trans men, that is to say women who want to become men, it involves removing the chest. Conversely, when it is men who want to become women, it involves putting on prostheses. I do both.

There's a lot of talk about trans people at the moment. Is this a new phenomenon or has it been around forever?
It has always existed, but it has indeed taken on extremely significant proportions. 30 years ago, I operated on one or two transsexuals per year. Today, I see several per week. The number of requests from transsexuals has clearly exploded. 

Trans people are often singled out, but we may not realize the suffering of these people. Do you feel it?
Cosmetic surgery is not a consumption exclusively linked to suffering. There is also desire, pleasure. There is perhaps the suffering of not being born in the body that we would like, but there is also the desire for the other body. And I prefer desire to suffering. Cosmetic surgery is the expression of individual freedom. 

Are they mainly women who want to become men, or the other way around?
There are 75% of transsexuals who are women wanting to become men. They suffer from the pain of having breasts, but there is also the desire to have a flat chest. 

Do trans patients ever have regrets?
This is our terror. Every time we operate on a transsexual, we are terrified that he will regret his decision. And obviously, we are all the more terrified if they are young…

What is the average age of these patients?
There is everything. I don't operate on minors at all, but I see patients from 20 to 75 years old. 20 year old patients scare me more than 75 year old patients. 

Why ?
I am always afraid that young patients will come to see me a few years after the operation and say: “You saw me in a moment of confusion, you are a doctor, you have not diagnosed my distress, you "did not diagnose the fact that I was not able to make a decision, you operated on me, but you mutilated me." 

And has this ever happened to you?
No. I must admit that among those we have operated on at the breast institute, for the moment, no one has told us that they regret their intervention. 

Is there a minimum reflection period imposed for an intervention?
It's case by case, we can't judge. To summarize, there are two completely different situations. If I see someone who is 25 years old, who has been followed since the age of 6, who sees an endocrinologist, who is under hormonal treatment, who is followed by a psychiatrist, all of that is very consistent. I don't really have to impose a deadline. It’s obvious that I’m following the logical progression of what’s been happening since the beginning. 

And the other situation?
If I see a young adult who did not ask questions before the age of 12-13, who is not followed by an endocrinologist, who is not followed by a psychologist, I am in a situation which is radically different. There, I am on the front line. If there is no other doctor who has worked with this person and who has looked into their motivations, I will be more suspicious, I will impose more deadlines, I will discuss, ask for opinions...

Is there a way back?
There is always a way back. Since we do reconstructions after cancer, we can do reconstructions. But sometimes it's still complicated. It leaves scars. 

There are scars in all cases...
Yes, but when we have scars because someone saved our life from cancer, it's different than if we have scars because we had a moment of confusion at the age of 20 years. We will experience it in a completely different way. In one case we will say to ourselves: “They saved my life”, and in the other case, we will think: “They mutilated me, they abused me”. This is the last thing I want to be responsible for. 

Finally, what would you like to add?
Cosmetic surgery is an empowerment over fatalities such as genetics, destiny, the passage of time, and the accidents of life. And I find that there is something quite liberating in this taking power over one's life, over one's body, one's appearance. That's why we see more and more people who decide that it's their body, that it's up to them to decide. 

It's beneficial ?
Having power over one's appearance and the freedom to use it I believe is beneficial, at least it is for me. To feel a little author of what we are, to be able to do something about it, that seems reassuring and cheerful to me. Plastic surgery is never an obligation, it is a tool available to those who need or want it. It is the expression of individual freedom and ownership of one's body. From this point of view, the interventions of transsexuals are an ultimate expression of this freedom. It is interesting to see that this wave of transsexual surgery simultaneously affects almost all Western countries and that countries like Russia, China and Arab countries see it as a sign of Western decadence.