Many Breast Cancer Patients Satisfied With 'Going Flat' After Mastectomy

Although breast conservation therapy (lumpectomy) was established as the preferred surgical intervention for early breast cancer in the 1990s, increasing numbers of women have opted for mastectomy, or bilateral mastectomies, over the past decade. Sometimes this choice is medically recommended, but much more often, the prognosis is the same following either mastectomy or breast conservation therapy. That is, women do just as well with the smaller breast-preserving surgery.

If we are given honest information and full support for our decisions, we will make the right choices.

Over the years, I have talked with many women as they struggle to make a surgical decision. Most of us are terrified by the diagnosis and compelled to do whatever we can to stay healthy and alive. Many of us have an initial reaction of get them off; get rid of all the cancer. Others cannot imagine living happily without breast(s) and never consider mastectomy as a good option. In considering our choice, we depend upon our doctors’ recommendations and our own instincts. It has always been my experience that we know ourselves well and make the right choice — whatever it is.

A recent study published in Annals of Surgical Oncology examined a different question. The survey of almost 1000 women who had opted for mastectomy without reconstruction, otherwise known as “going flat,” found an average satisfaction level of 3.72 on a 5-point scale. The strongest predictor of low satisfaction was a perceived lack of support from the surgeon for this decision. Shockingly, but not surprisingly from my experience, at least 20% of the women felt that their surgeon disapproved of the choice, and this perception was strongly related to a lower level of satisfaction with the surgical outcome. 

This study contrasted with others that have demonstrated a better quality of life and satisfaction with body image for women who had chosen reconstruction. This was not the case this time. Although the study did not say too much about this, I would bet that one big reason for dissatisfaction was less than optimal surgeries. A slightly different mastectomy is performed if the expectation is that reconstruction, either immediate or at a later time, will be part of the process. If reconstruction is anticipated, some excess skin is intentionally left to make space and room for that surgery. I have worked with a number of patients who describe being very clear and adamant with the surgeon about their choice to not have reconstruction. Several have told me that they engaged in a lengthy discussion about their wish to have a tight tissue closure and to have a flat chest post-surgery. Instead, they awakened to find that there was excess skin left behind. One woman told me that her surgeon acknowledged that had been purposeful, in spite of the woman’s directive, and even said “This way you can even have a little cleavage with the right bra.” The patient was appropriately furious.

It also should be noted that obesity or a higher-than-average BMI can make it technically more difficult for a surgeon to achieve a tight closed and flat chest post mastectomy. Some of the dissatisfied women may have been in this group.

For a number of years, there has been concern that reconstruction was less available for minorities and women of fewer resources. Many efforts were made to address this disparity, and the numbers seem to reflect some success. As time has passed, even with information about and access to immediate breast reconstruction (IBR), increasing numbers of women have opted to “go flat.” As often happens, this has resulted in a rise in advocacy groups and online communities to increase awareness and acceptance of this choice. Against that background, the new concept of flat denial has emerged: surgeons who push for reconstruction and sometimes don’t even mention another possibility. In the most distressing cases, situations like the ones described earlier may arise: surgeons ignoring the woman’s expressed issues and doing what they feel is right.

Overall, this study supports my long clinical experience. Women need and deserve to be given full information about the three possible choices after mastectomy: no reconstruction, an implant, or autologous reconstruction. Implant surgery may involve the use of expanders or the permanent implant can sometimes be placed at the time of surgery. Autologous reconstruction choices are varied and dependent on the woman’s physique and the surgeon’s preferred strategies. If we are given honest information and full support for our decisions, we will make the right choices.