Choosing to have a mastectomy is a big decision. Once you have taken this step, you and your breast cancer surgeon will discuss the options for reconstruction. An increasing number of women are choosing to “go flat” after a mastectomy rather than having their breast(s) reconstructed. In fact, a 2023 study showed that about 62% of women chose to go flat rather than have breast reconstruction. It’s a highly individual choice based on your personal preferences.
Let’s look at the options after a mastectomy and what you should tell your surgeon if you know you’d like to go flat.
What Are My Choices After a Mastectomy?
According to Rocky Mountain Breast Specialists’ breast cancer surgeon Dr. Gerlinde Tynan, “Patients undergoing mastectomy have two options, no breast reconstruction or reconstruction with implants, flaps, or a combination thereof.”
Research that compares women who had breast reconstruction with women who chose to go flat found no differences in quality of life, positive body image, or sexual intimacy.
Breast Reconstruction
Reconstruction surgery restores the breast to its pre-cancer shape, size, and appearance. In some cases, surgery to adjust the other breast may also be needed to ensure they’re both approximately the same size. The implant can be placed at the time of mastectomy or delayed until later after you recover from breast cancer surgery. If you require radiation therapy, reconstruction may be delayed until these treatments are done.
Reconstruction implants are made of saline or silicone. Another option is to use your own tissue from another place in your body (autologous tissue), or your surgeon may use a combination of autologous tissue and implant. If a nipple-sparing mastectomy is performed, the nipple and areola will remain intact on the breast during reconstruction. Many women maintain some sensation in the nipple with this procedure.
No Breast Reconstruction
Going flat requires no reconstruction surgery. Dr. Tynan explains, “In patients who plan reconstruction at a later date, certain landmarks such as the cleavage between the breasts and the inframammary creases beneath the breasts are left in place. A little bit of excess skin is not a problem, as it will be incorporated into the reconstruction later. However, with a flat closure, the cleavage and creases need to be removed along with the extra skin, so the chest wall is flat and blends naturally with the remaining soft tissue of the underarms, flanks, and abdomen.”
Women decide to go flat for a variety of reasons, such as
- Avoiding additional surgeries
- They are comfortable without a breast
- They are concerned about how a reconstructed breast will look or feel, including scars that may be the result of the reconstruction
- A shorter recovery time from the mastectomy
For those who go flat, they have the option to use an external breast prosthetic that can be inserted inside a mastectomy bra. Underneath clothing, a prosthetic breast provides a profile similar to your pre-cancer appearance.
Discussing Options With Your Partner
Preserving your self-image is very important to a successful recovery from cancer. For most women, at least some part of their self-image and self-confidence is reflected in how their intimate partner “sees” them. A frank discussion with your partner and family can help you decide. However, the final decision you make about your post-surgical appearance and reconstruction is entirely yours.
Will Surgery Be Different for a Flat Closure?
Breast surgeons will close the area differently when they know the patient wants to go flat. “Women who choose to go flat after surgery should ask for an aesthetic flat closure,” says Dr. Tynan. Also referred to as a post-mastectomy chest wall reconstruction, it is the “gold standard” for this surgery and offers the best results with the fewest side effects.
If the surgeon isn’t comfortable with the appropriate procedure for going flat, you can find one who is. Dr. Tynan explains, “If a woman chooses to go flat, the incision will typically run horizontally across the entire chest to both sides, sometimes with a V-shaped or hockey-stick pattern at the ends. Breast surgeons use different techniques to achieve a flat closure, depending on the anatomy the patient has going into surgery. Personally, from the surgeon’s perspective, I believe there is both an art and a science to getting a good result!"
Recovering From a Mastectomy With an Aesthetic Flat Closure
In general, recovery time for an aesthetic flat closure is shorter than for patients who have breast reconstruction. Depending on the individual, it takes about 3-4 weeks or a little more, compared to 6-8 weeks or more when reconstruction is planned. Patients who go flat usually experience less discomfort and fewer complications.
Your oncology care team will give you instructions on how to care for the incision, recognize signs of an infection, and care for yourself as you recover. Your team will explain your activity restrictions, and what to do about side effects. After surgery, you will have checkups to assess your recovery and any side effects you’re having.
There is no deadline for recovery. Take your time to adjust to your new appearance. If grieving seems to be going on too long, don’t hesitate to ask for a referral to a professional who can help you learn to adjust and cope in healthy ways.
What if I Change My Mind About Going Flat?
After the process of healing, you may decide that going flat is not your best option. This is perfectly acceptable and you can go forward with breast reconstruction in most cases. Federal laws requiring insurance companies to cover breast reconstruction are not time-limited. You can have reconstructive surgery at any time.
Consulting with a Breast Surgeon
We encourage you to talk frankly with your breast surgeon about what you would like. If you don’t feel comfortable with the surgeon’s experience using an aesthetic flat closure, don’t hesitate to get a second opinion. Dr. Tynan is experienced in these closures and will meet with you for an initial consultation or a second opinion. Her office is located in Longmont, Colorado. She works closely with the medical oncologists and radiation oncologists, who are also key members of each patient’s breast cancer care team at Rocky Mountain Breast Specialists.
