Going Flat after Mastectomy

To reconstruct or not to reconstruct breasts: What was your choice?

When a woman must have a mastectomy, her choices are limited. Several kinds of reconstruction may be offered and then there is the possibility of no reconstruction or going flat. I recently read a wonderful memoir by Catherine Guthrie called Flat: Reclaiming My Body from Breast Cancer. Like most memoirs, it is about much more than a single topic -- her difficult cancer experience -- but at the center is her choice not to reconstruct and the problems she experienced from her (not in Boston) physicians. I recommend it.

The book has also stimulated my thoughts about these choices. As you may know, a growing number of women are opting for single or bilateral reconstructions after mastectomy. The number of mastectomies increased as a result of the Angelina Jolie Effect, after the actress publicly described her decisions and experience. Remember that she opted for this surgery because she carried the BRCA gene; it was a prophylactic surgery, not one done in response to a cancer diagnosis.

The intent of this essay is not to discuss the various rationales for choosing or needing a mastectomy, but to consider the small but increasing numbers of women who are opting to go flat. One of my ongoing campaigns with Beth Israel Deaconess Medical Center breast surgeons has been to push them to always include this option in the list. All too often, I hear from patients that they were told something like: "I'm sorry to tell you that you do need a mastectomy to properly treat the cancer. But, you can have immediate reconstruction….". The train leaves the station at that point, and it is pretty hard for a scared and overwhelmed woman to apply the brakes. Meeting with a plastic surgeon to learn about the possibilities is always a smart move. Those choices will be dictated by the specifics of the cancer, the woman's body, and the surgeon's preferences. Again, all too often, the possibility of "only" having a simple mastectomy is not discussed.

There are many reasons why someone might prefer to decline reconstruction. It is more surgery -- sometimes a lot more depending on the type -- and there are always risks with any surgery. Some women aren't happy with the idea of moving around muscles or fat or having something artificial placed in their bodies as happens with implants. Some women who are serious athletes or musicians worry even more about possibly damaging their range of motion or strength. Some women just don't like the idea of doing more than is necessary for their cancer health. Some women feel that the pressure to consider reconstruction is evidence of a male-dominated society.

Some women simply think they can make peace with a changed or flat body. They understand that they can always return for reconstruction if that seems preferable in the future.

If you are a breast cancer patient considering reconstruction, here is an excellent resource. The website offers pictures and a great deal of information about surgery, prostheses and clothing.

The important point here is not that any one choice is better than any other. I am a firm believer that women know themselves and their needs and should be supported in the choice that feels right to them. In all my years of doing the work, I have known only a few women who regretted their decision. A few had reconstruction that brought a lot of complications, and they later wished that they had minimized the surgery and risks. I knew one women who, after a few years, decided that she did not like her flat chest and came back for reconstruction. Most women can come to believe the words of one of our breast surgeons: Some women have have two breasts, and some have one, and some have none... And they are all beautiful