Living Flat After Mastectomy: What Patients Are Saying About Flat Closure

In a study by the Journal of Clinical Oncology, roughly 25% of double-mastectomy patients and 50% of single-mastectomy patients opt out of reconstructive surgery. And experts have noted the following reasons as to why they choose this route post-op:

• Health issues that make multiple surgeries inadvisable for their bodies
• The need to recover quickly and resume certain activities
• Concerns about the cost, especially if their insurance doesn’t cover it

The decision to forgo reconstruction is also known as “going flat” or “living flat.” It’s an option not only for those who receive a mastectomy. An explant surgery, or the removal of an implant, is typically followed by an aesthetic flat closure. The procedure involves the remaining tissues being tightened and smoothened out to reveal a flattened chest wall.

Most plastic surgeons provide reconstructive options during initial consultations and encourage it to help restore the feeling of being whole. In some cases, an artificial implant rebuilds the look and shape of a breast. There’s a more natural approach to reconstruction; surgeons can use a flap of tissue from another area of the body for procedures called DIEP Flap or SGAP Flap.

But they often leave living flat out of the equation. Going flat has gained popularity in recent years, with women speaking up and empowering others to do what they believe is best for their bodies. It’s become a movement aside for body positivity, a message that cancer survivors can still feel as beautiful and confident if their chests are flat.

There are also several benefits to flat closure, such as:

• Not needing to wear bras
• Reestablished balance and better posture
• Decreased back pains from the removal of weight in the chest area
• The freedom to perform exercises without the breasts getting in the way

Ever since we started offering the procedure, we’ve had over 50 patients per year who wished to keep their breasts flat after their mastectomy. If you are currently a candidate for mastectomy and have yet to decide if you want a breast reconstruction, you can explore choosing a flat closure instead.

A mastectomy without reconstruction has its health benefits, and you can reach out to support groups and organizations to help you make your decision. What is paramount in this process is that you hear about all your options and are empowered to choose what you believe is best for your body.

You Are Not Alone In This Journey

A UCLA Jonsson Comprehensive Cancer Center report showed that 74% of women who opted to go flat after mastectomy were satisfied with their decision. And while the factors that lead to this choice vary, a consistent element that played a pivotal role is surgeon support.

In her memoir, FLAT: Reclaiming My Body After Breast Cancer, health journalist Catherine Guthrie talks about how she encountered numerous stories of women who had initially wanted a flat closure. But during surgery, their doctors would convince them to change their minds. Even worse, some would leave extra flaps of skin on their chest. So, they would wake up, see excess skin left, and feel like their doctor had violated their choice.

Knowing that this happens to women each day, Catherine met with her surgeon fully decided on staying flat.

Flat Closure Now, of which I am a member of its advisory board, is an advocacy group dedicated to educating women that choosing to go flat is a valid, healthy, and beautiful option after a mastectomy or explant. We also remind them that whatever they decide to do after surgery is their right.

Support Group & Communities

Aside from Flat Closure Now, there are other support groups that you can reach out to, especially if you’re weighing your options and would like to hear the stories.

The Patient Experience

Many patients still face an uphill battle from well-meaning doctors who encourage reconstruction to feel complete. But what I’ve noticed is that many surgeons struggle to support flat closure because they’ve become too caught up in enforcing cultural standards of beauty.

But they fail to realize that our role as surgeons is to help our patients achieve the best outcome for them. While we take what’s aesthetically pleasing into consideration, we should also think about what’s beneficial for their overall health. The result should always contribute to improving their quality of life. A flat closure doesn’t mean we’ve failed them, but it could assure them of a better future.

Kim Bowles is a Pittsburgh-based scientist and cancer survivor. After a distressing encounter with her surgeon, she began advocating for flat closure. Like in Catherine’s stories, Kim woke up after her surgery to find her doctor had left extra skin. He reasoned that it was in case she wanted reconstruction in the future.

She calls it “flat denial,” an experience that served as the foundation for her advocacy to raise awareness and acceptance of flatness. With more people like Kim speaking up, the world is embracing living flat. On October 7, 2019, the first-ever International Flat Day was celebrated by women worldwide.
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Many of our patients have reported discovering a new sense of self that lets them live happier, healthier lives after starting their flat closure journey.