Most Women Are Satisfied Without Breast Reconstruction
"Going flat" works for the majority of breast cancer patients.
Posted January 11, 2021
I have "gone flat," as have many women I know. That beguiling descriptor applies to breast cancer patients like me who do not have reconstruction after a mastectomy and therefore have pancake chests. After my bilateral mastectomy in 2015, I didn't want foreign material in my body. I miss my breasts, no doubt about it. In Western culture, breasts can define us as sexual beings; without mine, I feel a tad less desirable. Breasts equal beauty and I have the profile of a pencil. But I can remedy this with bras with prostheses that are comfortable and look natural, so why sign up for additional surgery and a continued need for medical surveillance?
Many other women choose differently, especially those who are younger; I understand and respect the importance of reconstruction for their own mental and physical well-being.
But my decision to “go flat” was right for me, and new research shows I am in good company.
The great majority of women who have decided against reconstruction are comfortable with their choice, according to a study published in the Annals of Surgical Oncology. Researchers surveyed 931 women who had a unilateral or bilateral mastectomy without reconstruction.
Of the women surveyed, 74 percent were satisfied with their outcome. But 22 percent were dissatisfied with their surgical treatment, either because the surgeon did not offer the choice of reconstruction, did not support the patient’s decision, or intentionally left additional skin in case the patient changed her mind. Twenty-seven percent reported not being satisfied with the appearance of their chest wall. I fall into that category—I think my surgeon could have tried harder and I wish I'd had a plastic surgeon involved, but none of this changes my mind about not having reconstruction.
Women in the survey said they decided against reconstruction for a faster recovery and to avoid foreign material in their bodies. In some cases, reconstruction was just not important for their body image. Count me in all three categories.
"Undergoing a mastectomy with or without reconstruction is often a very personal choice," said Dr. Deanna Attai, an assistant clinical professor of surgery at the David Geffen School of Medicine at UCLA, and senior author of the study. "We found that for a subset of women, 'going flat' is a desired and intentional option, which should be supported by the treatment team and should not imply that women who forgo reconstruction are not concerned with their post-operative appearance."
The results challenge past studies showing that patients who chose not to undergo breast reconstruction tend to have a poorer quality of life compared with those who do have the surgery. But Attai and her team believe the survey tool commonly used in those surveys was biased towards reconstruction.
To avoid that bias, the team partnered with patient advocates to develop a unique online survey to assess why women chose to “go flat” and how they felt about it. They also identified concerns unique to these patients not captured by other validated surveys.
"Some patients were told that excess skin was intentionally left, despite a preoperative agreement to perform a flat chest wall closure, for use in future reconstruction, in case the patient changed her mind," Attai said. "We were surprised that some women had to struggle to receive the procedure that they desired." Surgeons may hesitate to recommend mastectomy without reconstruction because they are less confident that they can provide a cosmetically acceptable result for patients who want a flat chest wall, she said.
"We hope that the results of this study will serve to inform general and breast surgeons that going flat is a valid option for patients, and one that needs to be offered as an option," she said. "We also hope the results may help inform patients that going flat is an option, and to empower them to seek out surgeons who offer this option and respect their decision."
Jennifer L. Baker, Don S. Dizon, Cachet M. Wenziger, Elani Streja, Carlie K. Thompson, Minna K. Lee, Maggie L. DiNome, Deanna J. Attai. 'Going Flat' After Mastectomy: Patient-Reported Outcomes by Online Survey. Annals of Surgical Oncology, 2021; DOI: 10.1245/s10434-020-09448-9