In late 2020, Lindsay R. heard the words she never thought she would hear: “You have breast cancer.”

“I immediately catastrophized in my head all the awful things that could happen to me and my kids as soon as I got the call on New Year’s Eve,” recalls this active mother of two and busy health professional. “I knew better, but my reaction really surprised me. Despite knowing my outcome would be good, I immediately went to the worst-case scenario in my mind. It was a bit humbling and reminded me of the fragility of life, and I proceeded to love those around me a bit harder that day.”

After careful consideration, several medical consultations, and a good deal of soul-searching, Lindsay opted for a bilateral mastectomy – the removal of both breasts. Also presented with a number of options for reconstructive surgery, Lindsay chose a different path. ”It wasn’t a hard decision for me,” she shares. “I knew pretty quickly I wanted to go flat.”

Among the surgeries available to treat breast cancer, the choices any individual may face will vary depending on a number of factors, both medical and personal. Several considerations influenced Lindsay’s decision, with one overriding concern: “I wanted to get back to work and back to my life as quickly as possible.”

Like Lindsay, many who opt out of reconstruction prefer a minimalist approach to their surgery. Others may have medical conditions and/or surgical histories that pose obstacles to reconstructive procedures. The reasons for going flat are as varied and diverse as the women who make this choice. It is helpful for those considering going flat to communicate their wishes clearly to surgical providers, and to ask about their experience with a procedure known as the aesthetic flat closure. This is a specialized form of surgery that results in a smooth, flat chest wall after one or both breasts have been removed. Breast surgeons and plastic surgeons may be familiar with this procedure, and naming it can help facilitate those conversations.

“I have absolutely no regrets about my decision,” says Lindsay. “I love my results. My surgeon really listened to me, and she did a wonderful job creating an aesthetic closure.“

Sara S. also made careful, informed decisions after her breast cancer diagnosis in 2018. “I was advised that a single mastectomy was sufficient. Based on my diagnosis, it was a quick, straightforward decision, but still, it was a very scary and daunting experience. With only a few short weeks to make such a challenging and personal decision, I talked to lots of other women and researched vigorously. I checked out books from the Coalition with [post-mastectomy] photographs. I looked at images of women who had chosen reconstruction and at those who had chosen to go flat. The images were so helpful. When I learned there is limited sensation in reconstructed breasts, I was convinced to go flat. I also met with a highly recommended plastic surgeon to discuss potential procedures and my personal options. The surgeon told me that I could take my time to make a decision, and I could consider reconstruction at a later date. This helped me to decide. A single mastectomy with no reconstruction was a good choice for me.”

Sara is clearly satisfied with her outcome. “I asked my surgeon if she could create an incision that was more contoured, rather than straight across my chest. She understood, but told me that she would have to do what was surgically best. She ended up giving me what she called a ‘Nike swoop’. I like it! I also like that I have the sensuality of one breast. It’s not something that is talked about enough, but it makes a huge difference. My partner would agree.”

According to Pebble Kranz, MD, FECSM, IF, a sexual medicine specialist in the Rochester area, “We are sexual beings, no matter what happens in or to our bodies. So, of course people with or without breast reconstruction are able to function as sexual partners. For sure, loss of one or both breasts may be a major upheaval in the relationship with one’s body. And the loss of nipple sensation as well as overall breast sensation can have a tremendous impact. Meanwhile, human beings are capable of remarkable flexibility in what is pleasurable. There’s a technique called pleasure mapping to help people explore what feels good in their bodies as they are in the present. That is possible, and may be necessary, regardless of breast reconstruction.”

Visual aesthetics also matter, and those who go flat often find creative ways to honor their new bodies. Deb H., a survivor of both breast and gynecologic cancer, was not interested in reconstruction after her breast cancer diagnosis in 2017. “After the bilateral mastectomy and the abdominal hysterectomy, my body had three large scars,” she shares. “I wanted to change the scenery that I was faced with every day. 

I opted for a full chest coverup tattoo. I have a full-color floral cover-up that looks like lingerie. Every day when I see the tattoo, I feel empowered. I didn’t choose to get the cancers that I had, but I chose to change what I looked at each day.”

After recent scar revision surgery to remove excess tissue under her arms, Deb is even more pleased. “The surgery was well worth undergoing. I feel like a new and improved me.”

Among those who choose breast reconstruction, the overwhelming majority do well. But a few may find their path has detours. After her breast cancer diagnosis in 2014, Maureen D. initially chose to have a single, or unilateral mastectomy. At the time of her surgery, a tissue expander was put in place; a more permanent breast implant would be inserted at a later date. Her intention was to undergo the exchange surgery after completing radiation, which was also part of her treatment plan. However, she had to adapt. “My skin shrunk around the expander site after radiation and I developed lymphedema, so I wasn’t excited about having the surgery to get my expander swapped out for the implant. During a physical therapy session to treat my lymphedema about five years later, the therapist mentioned a plastic surgeon who was doing revision surgery that involved removing the implant and performing fat grafting. After meeting with her, I opted for this.”

Maureen’s choice was right for her. “I’m very satisfied with my results! My circulation, posture, and range of motion are much better… I think it’s important for anyone considering fat grafting to understand that, while it will provide more fullness, it’s not a new breast. I have chosen to wear a light weight bra form, which is ideal for me. I’m pretty active and this works perfectly for biking, swimming, yoga and Pilates.”

Another consideration for some is a procedure called Goldilocks surgery. This is an oncoplastic surgery technique, which combines cancer-removing surgery with cosmetic surgery. In the Goldilocks procedure, the surgeon or plastic surgeon uses the tissue left behind after a mastectomy to either construct a flat chest wall with no concavity or create a small breast mound. For those who prefer minimal surgery, it can offer a “just right” option between going flat and more extensive reconstruction procedures; hence, the name “Goldilocks.” It can also be used to achieve an aesthetic flat closure.

For those who choose to go flat, or are considering it, connecting with empowered individuals who have made similar decisions is a helpful first step. The Coalition offers opportunities to do that through our PALS program, our support/networking groups, and our private Facebook groups. Others who have “been there” can offer support that is truly meaningful.

As Lindsay sagely notes, “It is such a personal decision to make, and body image distortions typically go much deeper than a women’s breasts. In the end, what really matters is not what we look like, how we dress, or what others think of our bodies. What matters is how you live, how you love, and how you impact the earth and those around you.”
A few resources for those going flat:

• Thelma’s Boutique: post-mastectomy garments. Go to thelmasboutique.com or call 585-256-2460
• Knitted Knockers: lightweight hand-crafted prosthetics: available at the Coalition or go to knittedknockers.org
• Not Putting on a Shirt: education, advocacy and support: notputtingonashirt.org
• Flat Closure Now: 501(c)(3) nonprofit organization advocating for patients: flatclosurenow.org or find them on Facebook

Resources for this article:
ncbi.nlm.nih.gov/pmc/articles/PMC4886147/
ncbi.nlm.nih.gov/books/NBK470317/
ncbi.nlm.nih.gov/pmc/articles/PMC6759440/#
cancer.gov/publications/dictionaries/cancer-terms