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Most Women Satisfied With Choice to Go Flat After Mastectomy, but Choice Not Supported by Many Surgeons

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Nearly 75% of women surveyed who opted for no breast reconstruction after mastectomy were satisfied with the results, but almost 25% said their decision to go flat was not supported by their surgeons, according to a study.

The research was published on Jan. 3, 2021, by the journal Annals of Surgical Oncology. Read the abstract of “‘Going Flat’ After Mastectomy: Patient-Reported Outcomes by Online Survey.”

What is going flat?
About the study
What this means for you

What is going flat?

While most women choose to have some type of breast reconstruction after mastectomy, a number of women decide to have no reconstruction.

There are a number of reasons why a woman might choose to have mastectomy without reconstruction. Some of the most common reasons are:

  • not wanting a foreign object, such as a breast implant, in the body
  • lower risk of surgery complications
  • lower risk of other health problems

The safety of breast implant reconstruction was a hot news topic in 2019 after the U.S. Food and Drug Administration (FDA) requested a global recall of Allergan Biocell textured breast implants and tissue expanders. The FDA requested the recall because of the products’ link to a rare form of T-cell lymphoma (cancer of the immune system) called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). For more information, read the Breastcancer.org Special Report on Breast Implant Illness and BIA-ALCL.

In recent years, advocacy groups and online communities have been formed as part of what is called the Going Flat movement to increase awareness and acceptance of mastectomy without reconstruction.

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About the study

“There were several studies published showing that women who did not have reconstruction had poorer quality of life compared with those who underwent some form of post-mastectomy reconstruction,” Deanna Attai, M.D., assistant clinical professor of surgery at the David Geffen School of Medicine at UCLA and senior author of the study, told Breastcancer.org. “However, I was interacting with women in the online community, and there are a growing number of ‘going flat’ patients and advocacy groups.

“These women and organizations were providing information and support and seemed very comfortable with their decisions,” she continued. “So it seemed like there was a disconnect between what I was seeing in the surgical literature and what I was exposed to in the online communities. We wanted to specifically reach out to the patients in the online communities to assess their experiences.”

The researchers discovered that the tool commonly used to measure quality of life and satisfaction with breast surgery results, called BREAST-Q, was considered biased toward reconstruction by many women who had no reconstruction. So Attai and her team worked with these patient advocates to create a new survey tool to ask about satisfaction with no reconstruction, as well as factors associated with satisfaction. The survey also helped the researchers identify concerns unique to women who choose no reconstruction that were not captured by other survey tools.

The survey asked:

  • how satisfied a woman was with the outcome of her surgery
  • why a woman decided to have no reconstruction
  • whether a woman had experienced what is called “flat denial,” meaning a woman’s surgeon advised against or didn’t offer the option of no reconstruction after mastectomy, or left extra skin in the breast area so reconstruction could be done in the future, even though this was against a woman’s wishes

The survey also asked about the demographic characteristics of the women, as well as the type of surgery they had and whether their surgeon specialized in breast surgery.

Overall, 931 women who had single or double mastectomy and currently had no breast mound reconstruction answered the survey, which was posted online Oct. 15-21, 2019.

The results showed that 74.1% of the women were satisfied with the results of their surgery. Still, 22.2% of the women said they had experienced a high level of flat denial. Women who had a high flat denial score were more likely to be dissatisfied with the results of their surgery.

The results of the study challenge earlier research showing that women who chose not to have breast reconstruction have poorer quality of life and are less satisfied with the results than women who do have reconstruction. “Undergoing a mastectomy with or without reconstruction is often a very personal choice,” said Attai. “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 postoperative appearance.”

The women who answered the survey could submit comments about their surgery experiences, and many wrote about flat denial. Some examples:

  • “I was never given the choice of going flat; it was like I was ‘expected’ to have reconstruction…”
  • “I stated multiple times that I intended to stay flat … after surgery they told me they left extra skin in case I changed my mind.”

The results also found that 27% of the women were not satisfied with how their chest wall looks.

“A woman who opts for no reconstruction still wants a neat/tidy appearance to the chest wall and surgeons need to become proficient with the techniques needed to achieve this, just as they have become proficient at removing the breast,” Attai said. “Unfortunately, little attention has historically been paid to the appearance of the chest wall after mastectomy alone. In some cases, no special techniques other than consideration of incision size and amount of skin removed are needed. However, at times some basic plastic surgical techniques are needed to minimize dog ears — the excess skin at the inner or outer aspect of the incision — redundant or excess skin, or excess side tissue. One of our hopes is that going forward, when a woman says she wants to go flat or forgo breast mound reconstruction, that the surgeon understands what the patient really wants is an aesthetic chest wall closure.”

Attai also pointed out that there are some limits based on weight, breast size, and body shape to how aesthetically pleasing the chest wall can look with no reconstruction.

“It's a lot easier to achieve an aesthetic flat closure in a patient that is lean with a smaller breast,” she explained. “That does not mean that a woman with a larger breast or one who is overweight can't expect a neat and tidy appearance, but it might take more work and more advanced techniques, or even more than one procedure.”

The results also showed the main reasons a woman chose to have no reconstruction were:

  • wanting a faster recovery
  • not wanting a foreign object, such as an implant, in the body
  • believing that breast reconstruction was not important for her body image

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What this means for you

If you’re considering having no reconstruction after mastectomy, the results of this study are mostly encouraging: nearly 75% of women who chose to forgo reconstruction were satisfied with the results.

Still, the study also found that nearly one-quarter of the women were not supported by their surgeons in their choice to go flat. Many woke up from surgery to find that the surgeon had left extra skin in the breast area, even though the women didn’t want this.

If you want to go flat after mastectomy, Attai recommends telling your surgeon very clearly what you want.

“I think the best women can do is be completely up front with their surgeon,” she advised. “Bring in pictures if possible. One of the areas of work is to develop an online gallery of photographs [for women to use]. If there is a clear violation of what was agreed upon, there should be a clear explanation of why and attempts made to resolve the situation — but unfortunately that requires another surgery, [which means more] anesthesia. If the surgeon just does not support the patient preoperatively, I would recommend a second opinion if possible. Trust is important, and surgeon support of the patient’s decision was one of the factors most associated with patient satisfaction.”

If your surgeon doesn’t offer you the option to have no reconstruction or seems to think you’ll change your mind later, it makes sense to talk to another surgeon who supports your decision. You also may want to talk to a plastic surgeon who has experience doing aesthetic flat closure. This is the medical term for surgery that removes extra skin, fat, and other tissue in the breast area after mastectomy. The remaining tissue is then tightened and smoothed out so the chest wall looks flat.

For more information, visit the Breastcancer.org Going Flat page.

To talk with others about making the decision to go flat, join the Breastcancer.org Discussion Board forum Living Without Reconstruction After a Mastectomy.

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Written by: Jamie DePolo, senior editor

Reviewed by: Brian Wojciechowski, M.D., medical adviser


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