Published on May 18, 2020
Women having a mastectomy have myriad 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.1
Having a flat closure is optimal for a variety of reasons; some are wary of additional surgeries, while others want to return to their normal activities as quickly as possible. What is the path for deciding what to do after mastectomy? Shared decision-making.
Breast reconstruction specialist Minas Chrysopoulo, MD, FACS, says that shared decision-making is the key to getting the best outcome for patients. He created the Breast Advocate App2, to help patients become advocates for themselves by presenting all of the options for patients with breast cancer, including all types of reconstruction.
“The app was created to help patients guide the conversation with their surgeons,” he said, emphasizing the importance of seeking a second opinion to get the best outcome.
When the Surgeon Is the Patient
Liz O’Riordan, MD, a consultant breast surgeon in the United Kingdom, understands the importance of patient communication personally. She was diagnosed with stage III breast cancer at age 40. In 2015, she had a single mastectomy and implant reconstruction after chemotherapy. As a slim triathlete, she didn’t have enough tissue for a flap.
Three years later, Dr. O’Riordan had a local recurrence on her chest wall and went flat as part of her treatment. As a result of her experience, she is thinking of different ways to communicate with her patients.
“As a surgeon, I always offered women the full range of reconstructive options, looking forward to doing a more complex operation,” she said. “I would be a little sad when someone just wanted to go flat. As a patient, I now understand that choosing to go flat is no reflection on my own technique. It’s a very personal choice. In fact, I wouldn’t mind if every woman decided to go flat as long as they had been given all the information about all the choices. Opting not to undergo reconstruction surgery must be one of them.”
When Choice to Go Flat Is Ignored
Breast cancer survivor Kim Bowles founded an organization called Not Putting on a Shirt after her experience with breast surgery didn’t go as planned.3
Kim said her plastic surgeon left her with excess tissue to facilitate reconstruction, in case she changed her mind later, even after she had clearly communicated it was something she did not want. She then needed a follow-up surgery to achieve her desired appearance. Her goal now is to help women communicate that they have all options and that flat closure is one of them.
“It's an issue of women's rights and bodily autonomy,” Kim said. “When women are given full disclosure of all of our options, we can make the best decision for ourselves. Full disclosure must include flat closure as an affirmative aesthetic choice deserving of the same respect and consideration as traditional reconstruction,” she added.
Changing Perceptions of Womanhood
For many, breasts are a significant part of a woman’s life; from her appearance in and out of clothes, to how she feels sexually, and how they move when she is active. To decide to not have breasts at all is the choice for some women who want to get back into activity as soon as possible.
Baltimore-based ballerina Maggie Kudirka was diagnosed with stage IV breast cancer at age 23 while dancing with the Joffrey Concert Group in New York City.4 Her diagnosis briefly put her career on hold. Having already gone through a breast reduction at age 18, Maggie knew how she wanted to manage her disease, to “go flat.” Six days after her double mastectomy, she returned to the dance studio.
At age 38, health journalist Catherine Guthrie found a lump. It turned out to be cancerous, and initially she thought that she would have a lumpectomy and radiation. That did not turn out to be the best option for her, and she scheduled a double mastectomy with a flat closure instead of breast reconstruction. She wants people to know that going flat is one of the many options following surgery for breast cancer, and wrote about her experience in a memoir, FLAT: Reclaiming My Body From Breast Cancer.5
The “Going Flat” Movement
Some women find the humor in the absurdity of cancer. Comedian and breast cancer survivor Tig Notaro has done entire sets of her comedy routine topless following her double mastectomy with a flat enclosure. Tig talked about it on Late Night with Conan O’Brian and said it was liberating. “It was a long process, in getting comfortable with myself,” she said.
A review of 28 studies found that women who opted not to undergo reconstruction sometimes did better, in terms of body image, quality of life and sexual satisfaction than women who have gone through with reconstruction.6
There are many options on the table for patients. Ensuring that they hear all and are respected for their decisions is paramount, and patients who advocate for themselves get better results.
~Lauren Evoy Davis
Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.
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- Breast Reconstruction Is a Personal and Complex Choice
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- My Cancer Journey: Sexual Health After Cancer
- Jagsi R, et al. Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States. J Clin Oncol. 2014 Mar 20;32(9):919-26.
- Breast Advocate App
- Not Putting on a Shirt
- Bald Ballerina
- FLAT: Reclaiming My Body From Breast Cancer
- Lee C, et al. Patient-reported outcomes of breast reconstruction after mastectomy: a systematic review.. J Am Coll Surg. 2009 Jul;209(1):123-33.