What is your path for deciding what to do after mastectomy breast surgery?
A study published in Annals of Surgical Oncology in 2023 that examined the reconstruction rates from 2004 to 2019 showed that 37.5% of women had reconstructive surgery, whereas 62.5% did not. The proportion of women choosing flat closure after mastectomy declined for years until a landmark story in The New York Times in 2016 headlined “‘Going Flat’ After Breast Cancer.” After that, the proportion started to increase.
Women breast cancer patients having a mastectomy have numerous decisions to make regarding if, how, and when to undergo reconstruction, and for a growing number of women, “going flat” is the right choice for them. Approximately 25 percent of patients with breast cancer are opting out of breast reconstruction.
Performing breast reconstruction involves additional surgery, which may double the amount of time spent in the operating room. Depending on the patient, the severity of the cancer, and the amount of tissue removed, patients can choose to have a reconstruction using implants or their skin. Implant insertion takes at least two surgeries: one to place tissue expanders where the implant will eventually go and another to place the implants.
Tissue flap procedures, also known as autologous tissue reconstruction or tissue-based reconstruction, use tissue from the patient’s buttocks, thighs, or stomach to create a more natural-feeling breast.
The reconstruction portion of the cancer surgery may involve prolonged healing and recovery times, an increased risk for surgical complications, and additional procedures or surgeries in the future.
A flat closure is optimal for various reasons; some are wary of additional surgeries, while others want to return to normal activities as quickly as possible. Alternatively, some women may choose a “one-and-done” path, which may mean less risk, fewer post-surgical complications—both early and in the future—and the potential for a shorter recovery time. Eliminating breast reconstruction surgery and going flat is a way for women to reduce risks and complications while getting back faster to activities they enjoy.
Breast Implant Removal
Some common reasons that women may choose to have their breast implant breast implants removed include: An MRI has revealed a problem with your implant(s). All women with silicone breast implants should periodically undergo MRI testing to make sure their implants haven’t ruptured. Though silicone isn’t toxic, ruptured implants can cause pain, irritation, and infection if left untreated.
Your Lifestyle or Preferences Have Changed: If you feel like your breast implants are too large or too heavy, they can be replaced with smaller implants or removed entirely.
Health Concerns That Make Surgery Necessary: Breast implant removal is medically necessary for women who have received a diagnosis of breast cancer as it can interfere with treatment. Some women choose to have their breast implants removed because they’re experiencing non-specific symptoms, like fatigue and unexplained fevers, and they think their symptoms are related to having breast implants. This condition is known as breast implant illness, and while it’s poorly understood at present, researchers believe an autoimmune reaction may cause it.
A few options after removing implants:
Implant Exchange: The original implants are removed, and new implants of your choice are placed into the existing “pocket.” The recovery time is the same as that of the original reconstruction surgery.
Breast Lift with Implants: Large natural breasts, surgically augmented breasts often sag over time. If you’ve had breast implants for many years, normal aging and the effects of gravity may have created loose, stretched skin around your implants. To ensure your new implants sit in the correct position, surgeons may combine your implant exchange with a breast lift. They’ll remove excess skin from your breasts, insert new implants, and adjust the position of your nipples, as needed.
Thanks to the Women’s Health and Cancer Rights Act of 1998, most health insurance plans now cover Aesthetic flat closure (excess skin and fat are removed to make the chest appear as flat as possible, reconstructive surgery for eligible patients.
In some cases, surgeons have gone against their patients’ wishes for flat closure, performing a skin-sparing mastectomy instead. The reason? If the patient changes their mind about implants in the future, it’s easier for a surgeon to place implants if some skin is left behind.
Going Flat What Happens Next?
The breast tissue and most breast skin are removed if you go flat, leaving the chest flat or slightly concave. The incision will typically run across the middle of the chest. It may be possible for you to have a nipple-sparing mastectomy, even if you choose not to reconstruct.
Consult your surgeon for an “aesthetic flat closure” defined by the National Cancer Institute so they understand you want a smooth, flat chest with no extra skin left behind. You can change your mind about going flat and undergoing delayed reconstruction with tissue or implants at any time in the future.
Your Weight Can Play a Role
A higher BMI was one of the most significant indicators among patients unhappy with the decision to go flat. Surgical satisfactory results can be challenging to produce in overweight or obese patients. From a technical standpoint, giving a neat chest wall closure to someone with a smaller breast is much easier. Someone who is overweight or obese has more excess skin and fat rolls, so it is difficult to achieve a flat closure, but it can be done.
For breast cancer patients with a higher BMI, a flat chest wall closure may take more than one surgery to receive the desired effect.
In recent years, advocacy groups and online communities have been emerging as part of the “going-flat” movement to increase awareness and acceptance of mastectomy without reconstruction. The correct decision is whatever is best for the patient. No two cancers are alike, which means one woman’s cancer journey may look very different from her family members or friends.
Yearly during October, Breast Cancer Awareness Month, October 7th is designated as International FLAT Day (Not Putting On A Shirt).
Going Flat Day advocates flat closure as a valid choice post-mastectomy and encourages doctors to present it as an option to their patients. By increasing awareness about the option to go flat, they hope to improve the aesthetic outcomes for women who go flat and empower them to make informed decisions about their surgery. Not Putting on A Shirt celebrates women who have chosen to go flat and helps them embrace their beauty and sensuality without their breasts.
Various Reasons to Go Flat | You may choose not to reconstruct because you:
- Want to avoid additional surgery.
- Want to return to your routine as quickly as possible.
- Are comfortable with the idea of a flat chest.
- Are undecided about reconstruction at the time of mastectomy.
- Have a health condition that precludes additional surgery.
- Need radiation after mastectomy.
- (For reconstruction after radiation, the plastic surgeon can insert and inflate a tissue expander after mastectomy to preserve the breast skin and shape for later reconstruction—this is called a “delayed-immediate” procedure).
Patients who opt for no reconstructive surgery still want the look of their natural breasts and wear prosthetic breasts. If you’ve been using a prosthesis and are considering going without it but are uncomfortable with it, try not wearing it while at home. Then try working your way up to going without it for short errands and see how you feel. You may realize most people don’t even notice!
If you like going flat but are worried about looking uneven in form-fitting clothing, choose styles that draw attention away from your chest area.
BreastFree.org has some great clothing tips:
• Fabrics with busy, irregular patterns that aren’t too small, such as florals and paisleys, keep the eye moving
• Dark colors, predominantly black, camouflage the lack of shadow underneath the flat part of your chest
• Crisp shirts with breast pockets mask your contours
• Jackets and sweaters, layered over form-fitting t-shirts, draw attention away from your chest and hide any unevenness
• Scarves and shawls can be used to cover part of your chest
• Instead of plunging necklines, choose styles that show off your other assets, such as high necklines that bare your back or shorter/slit skirts that highlight your legs.”
SUMMARY
Patients have many options after a double mastectomy. Ensuring they are respected for their decisions is essential, and patients who advocate for themselves get better results. You might decide that you don’t want to wear a prosthesis or have breast reconstruction after having a mastectomy. You may choose to be flat.
Women decide to do this for various reasons. It might be because you:
- Don’t want to have more surgery
- May desire to get back to everyday life as soon as possible
- Don’t want to wear prostheses or find them uncomfortable
- Patients who are unhappy with their breast reconstruction results for whatever reason also have the option of going flat rather than further surgery to revise their reconstruction. Implants or tissue reconstructions (known as “flaps”) can be removed, and any combination of the above techniques can be applied to achieve an aesthetic flat closure.
- Patients with breast cancer or those who have a preventative mastectomy may have the option of forgoing reconstructive surgery. Many patients who decide not to have breast reconstruction are happy with their decision.
If you are trying to decide whether to “go flat,” talk to your oncologist and surgeon. Your surgeon and breast care nurse will discuss all your options and explain the pros and cons to help you make the right decision.
Some helpful organizations offer support to women who choose to be flat. You can connect with women with similar experiences through their online forums, Instagram, Facebook, Twitter, or face-to-face.
REFERENCES
BreastCancer.org
Breast Cancer Research UK
City of Hope
FORCE
Managed Healthcare
VeryWell Heathcare
