Reframing the Discussion for Surgical Options after Breast Cancer — Women are Choosing to ‘Go Flat’

CURE, CURE Winter 2022, Volume 21, Issue 4

After undergoing a mastectomy, women can either proceed with reconstruction or "go flat," but one expert says that the correct decision is what’s best for the patient.

No doubt about it: A breast cancer diagnosis can be devastating. Thankfully, breast cancer treatment has advanced. Many women are living longer and with greater quality of life and we are seeing higher cure rates than ever before.

But when the focus is on survival, sometimes the last thing on a patient’s mind after undergoing surgery are cosmetic outcomes.

As providers, it is crucial that we approach cancer treat- ment with the whole patient in mind. Equally important, treatments for both body and mind are essential to a patient’s recovery and restoration of self.

Even after cancer treatment and surgical intervention, patients are left with the scars of their past. As a surgeon, if I can somehow better a person’s cancer experience, no task is too big or too small. In fact, scar placement and surgical technique are among the ways I can help keep patients feeling whole. Inside my toolbox are “Hidden Scar” techniques, specialized oncoplastic techniques performed with the hope of minimizing scar visibility and saving the natural breast shape when possible.

There are several reasons, however, why removal of the entire breast — or mastectomy surgery — may be recommended for the treatment and eradication of breast cancer disease.

Why? Maybe a patient’s tumor is so sizable that the only way to surgically remove it is to remove the breast itself. Maybe a patient’s genetic mutation places her at such a high risk of getting another breast cancer that we perform mastectomy surgery for preventive reasons. Or maybe a patient decides to remove the majority of breast tissue for peace of mind; they no longer want annual mammograms or MRIs for screening surveillance because they know they will be a giant ball of nerves every time they need to get a screening study, and the thought of having an emotional roller coaster is just too much.

Each of these reasons is equally valid and important and each shows why the decision to have mastectomy surgery is personal and possibly very complicated.

What happens once a breast gets surgically removed? Generally, there are two options. Surgeons can close the incision and skin over the chest wall, which is now lovingly referred to as “going flat,” or we can rebuild a new breast for patients, commonly referred to as breast reconstruction.

The latter option is often a very personal decision, but a point I emphasize with my patients is choice. The cancer treatment journey is theirs and so are the decisions they make along the way. This is where empowerment begins.

For some patients, having a breast mound is part of how they identify as women. When they choose to rebuild the breast after mastectomy, either by using an implant (a foreign body) or by using their own tissue from various parts of the body, we recreate a breast shape and form.

Performing breast reconstruction involves an additional surgery following mastectomy surgery, which can easily double time in the operating room. The truth is, breast reconstruction may involve multiple surgeries in a stepwise fashion to obtain the desired result. Depending on the patient, the reconstruction portion of the cancer surgery can introduce prolonged healing and recovery times, an increased risk for surgical complications, and additional procedures or surgeries in the future, especially if chemotherapy or radiation is part of treatment.

Alternatively, some women opt for a path that likely takes on less risk, which can mean fewer post-surgical complications (both early on and in the future) and a potential for shorter recovery time.

Sometimes the adage “less is more” holds true. Eliminating breast reconstructive surgery and “going flat” can be a way women minimize risk and complications while getting back to activities they love faster.

Here’s my take-home message for my patients who choose not to have reconstruction: Going flat does not equate to going without. In fact, once healed from surgery, patients can get fitted for a prosthetic insert and bra from a specialized breast cancer store that offers personalized fittings. These garments, often covered by insurance because of medical necessity, allow women a nice and natural breast shape under clothing without anyone knowing the difference.

To the women who rock a flat physique after mastectomy: Yes, you are beautiful, too!

When it comes to breast cancer surgery, there are no wrong decisions — only personal decisions. After surgery, scarring is inevitable as a natural part of rebuilding and healing. Scarring can sometimes take on a negative meaning, but what if scars could be a beautiful thing?

Through my lens, breast cancer surgery underscores a woman’s strength, courage and tenacity to face the odds. So let’s change the narrative together and respect personal choice.

Dr. Carolyn Bhakta is a breast surgical oncologist and oncoplastic breast surgeon at Cancer Treatment Centers of America in Chicago.

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