Going Flat: Choosing No Reconstruction

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While most women choose to have some type of reconstruction, some women don’t want to have additional surgery. Some also don’t want to deal with special bras, magnets, or adhesive patches that hold a prosthesis in place. They choose no reconstruction and don’t wear a breast form most of the time. Many women and doctors call this “going flat” or “living flat.”

If you've had one breast removed and feel self-conscious about looking lopsided, try going without a breast form at home. Then try running an errand or going out for coffee without your prosthesis. You’ll probably find that people don’t notice the difference, or if they do, it’s not a big deal.

A 2014 study found that about 56% of women had reconstruction after mastectomy, which means that 44% didn't have reconstruction. Women who choose not to reconstruct may do so for a number of reasons, including:

  • health issues that make the one or more surgeries involved in reconstruction out of the question
  • the need to more quickly resume daily activities
  • concerns about losing muscle strength with autologous (or flap) reconstruction (although keep in mind that there are procedures that can avoid cutting muscle at the flap donor site, as well as the option for implant reconstruction)
  • concerns about cost if you don’t have insurance coverage

The decision to reconstruct or not is very personal. There is no “right way” to approach mastectomy and reconstruction (or lack of it). There is only the way that is best for you, your preferences, and your healing.

Some women who want no reconstruction say their doctors just assumed they wanted reconstruction or that they’ve felt pressured by their doctors or family members to have reconstruction.

If you feel that your doctor isn’t fully listening to you or isn’t taking your choice of no reconstruction seriously, make an appointment with another surgeon to get a second opinion. Because the choice to reconstruct or not is very personal, you need a surgeon who listens to you and explains things in ways you can understand. It’s also important that you know all of your reconstructive options, especially if those initially presented to you aren’t appealing. Studies from the American Society of Plastic Surgeons have found that more than 70% of women aren’t fully informed about their reconstructive options before mastectomy.

If you’re having trouble explaining your decision to your spouse or other family members, a therapist, counselor, or social worker can help guide you through difficult conversations. Your doctor or nurse will likely have recommendations.

Recovery and aesthetic issues

Recovering from a mastectomy with no reconstruction is generally easier than recovering from mastectomy with reconstruction. If you have immediate reconstruction (reconstruction at the same time as surgery), the recovery time is longer than it is with no reconstruction. Depending on the type of procedure you have, there may be some muscle weakness and/or mobility issues as well, although some of the newer flap procedures minimize this risk by preserving the muscle structure at the tissue donor site. Generally, immediate reconstruction does lead to the most cosmetically pleasing results.

If you choose delayed reconstruction — reconstruction 6 or 12 months or more after mastectomy — your recovery from mastectomy should be a bit easier. If you choose implant reconstruction, your doctor may need to use a device called a tissue expander, which is used to create a pocket under the skin where the implant will eventually go. If you have a tissue flap reconstruction, the skin that was removed at mastectomy will be replaced with the skin that comes with the flap (if reconstruction is performed at the time of mastectomy, this skin replacement may not be necessary).

There are some aesthetic (appearance) issues to consider if you’re not having reconstruction after mastectomy. Some women, especially women who have large breasts or are overweight or obese, may end up with what are called “dog ears” under their arm. These are pockets of fat left behind after mastectomy. Also, if an incision ends abruptly, a “tab” of skin and/or fat may form a bulge at the end of the scar or under the incision. Most women prefer scars that lie flat, leaving their chest fairly smooth.

It can be helpful to show your surgeon pictures of women who’ve had mastectomy with no reconstruction with results you like. The website BreastFree has photographs of good no-reconstruction results.

Questions to ask your surgeon

If you’ve decided not to have reconstruction, here are some questions you may want to discuss with your surgeon:

  • How many women in your practice have opted for no reconstruction?
  • Do you have pictures of women who’ve had mastectomy with no reconstruction?
  • How will you make sure that the mastectomy scar(s) lay flat against my chest?
  • How will you make sure that I don’t have any dog ears or tabs?
  • What results are realistic for me?
  • How will my chest area feel to the touch?
  • Will I have any feeling in my chest area?
  • Can you connect me with other women who have opted for no reconstruction?

Sexuality and no reconstruction

You may be wondering about your sex life after mastectomy with no reconstruction. For a number of women, breasts are an important erogenous zone. You may be worried that the loss of your nipple and some of the feeling in the breast area may change your sex life for the worse. You might worry that your partner doesn’t find you attractive with only one or no breasts (if you’ve had a double mastectomy).

What do partners of breast cancer patients care most about? In spite of what you may imagine or fear, studies show that the answer is simply this: Their loved one is alive and feeling well. The loss or alteration of a breast is almost meaningless in contrast. "I don't care what they take from you as long as I can see your face," is a common sentiment. Most caring partners (both men and women) see their lovers as having many parts to love and as being more than the sum of those parts.

Sex after mastectomy with no reconstruction can be just as fulfilling as it was before surgery. But you may need to experiment or change some things:

  • If you enjoyed wearing lacy, racy lingerie before your diagnosis, there are versions that can be worn with breast forms. If you’d rather not wear a prosthesis, then don’t — the whole point of lingerie is to make you feel alluring and special.
  • Some women say that wearing a breast form in a sports bra helps them recapture the feeling of having breasts.
  • Other women say that with the loss of one or both nipples, other erogenous areas, such as the neck or scalp, become more sensitive.
  • Touching habits may change. You and your partner may be tentative about touching your chest and your scars. Many people find it helpful to talk about what kind of touching they’re comfortable with before any intimacy begins. If you’re comfortable with some touching but your partner isn’t, you may have to be assertive and show and tell your partner exactly what you do and don’t want.

Sex and intimacy happen one step at a time. Give yourself time, give yourself love and affection, and give yourself credit for your hard work and courage.

Dressing after no reconstruction

If you like the idea of going flat but are worried about looking lopsided in form-fitting clothing, choose styles that draw attention away from your chest area. BreastFree has some great clothing tips:

  • fabrics with busy, irregular patterns that aren’t too small, such as florals and paisleys, keep the eye moving
  • dark colors, especially black, camouflage the lack of shadow underneath the flat part of your chest
  • crisp shirts with breast pockets mask your contours
  • jackets and sweaters layered over form-fitting t-shirts draw attention away from your chest and hide any unevenness
  • scarves and shawls can be used to cover part of your chest
  • instead of plunging necklines, choose styles that show off your other assets, such as high necklines that bare your back or shorter/slit skirts that highlight your legs

If you’re worried about not having nipples, you can buy removable polyurethane nipples. These nipples are in a semi-erect position and are very close to a natural nipple's texture and color. To attach the nipples, you moisten the back and stick them on — like a little suction cup. You can put them on and take them off as you'd like.

Center For Restorative Breast Surgery



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