Going flat after mastectomy means choosing not to have breast reconstruction after having one or both breasts removed.
Many people decide to have new breasts created after undergoing breast removal surgery. Surgeons can do this by transplanting tissue from elsewhere on the person’s body, known as tissue flaps, or by implanting synthetic material, known as implants. Other people decide to “go flat” and undergo a procedure called aesthetic flat closure.
Each person’s reasons for deciding to go flat are individual to them. They may want to avoid extending their recovery time or avoid the potential side effects and complications of breast reconstruction.
In 2021, research published in the Annals of Surgical Oncology found that around 75% of the 931 women surveyed were satisfied with their decision and results when undergoing a mastectomy.
This article explains the procedure, the recovery, and where to find information and support.
A person may decide to go flat after a mastectomy for various reasons. While some people may prefer to have tissue flaps or implants, others prefer not to for reasons such as these:
- They do not think that tissue flaps and implants could feel the same as their own breasts.
- They want to avoid a potentially lengthy breast reconstruction process on top of the other treatment they are going through.
- They want to return to physical activity as soon as possible.
- They do not want anything artificial in their body.
- They have concerns about scarring and side effects from tissue flap surgery.
- Their cancer has spread to other parts of their body, and they want to focus on their cancer treatment instead of reconstruction.
- They want to avoid future mammograms on reconstructed breasts.
- They want to avoid the potential complications of reconstruction, which can require further surgery.
Some people decide not to have reconstructive surgery for practical reasons. They may not have enough spare tissue to make tissue flaps, may not have the available funds for the procedure, or may have another condition that increases their risk of complications.
As mentioned earlier, in a study published in 2021 in the Annals of Surgical Oncology, researchers surveyed 931 females who had undergone a mastectomy of either one or both breasts. For all of these females, the mastectomy was a treatment for breast cancer or to reduce their increased risk of breast cancer.
Additionally, none of the participants had opted for breast reconstruction surgery, and almost 75% were satisfied with the results. However, nearly 25% said their surgeons had not supported their decision to go flat.
Most people decide to have reconstructive surgery after having a mastectomy to remove one or both breasts.
Reconstruction may involve transplanting tissue from elsewhere on the body, known as tissue flaps. Alternatively, a surgeon can implant synthetic material to construct the new breasts, known as implants.
However, some people decide not to have this additional procedure after having their breast tissue removed.
Aesthetic flat closure, or post-mastectomy chest wall reconstruction, is the gold standard procedure for going flat. It involves removing extra skin, pockets of fat, or excess tissue and tightening and smoothing the tissue that is left to form a flat chest wall contour.
Surgeons can carry out an “immediate” aesthetic flat closure at the same time as a mastectomy or a “delayed” aesthetic flat closure a few months after the mastectomy.
People undergoing surgery for breast cancer may receive care from a general surgeon or a breast surgeon. The surgeon’s job is to remove all the breast tissue and cancer and check the lymph nodes around the area for cancer.
A person can also ask to talk with a plastic surgeon, who can advise on reconstruction procedures, including going flat after a mastectomy.
Some surgeons strongly favor tissue flap or implant reconstruction over aesthetic flat closure, so a person may need to specifically ask to talk about this option. If a surgeon does not have experience with the procedure, a person may need to find another surgeon.
Points to raise with a surgeon might include:
- the surgeon’s experience with aesthetic flat closure, including how many procedures they have performed
- assurance that the mastectomy scars will lie flat against the chest, and how the surgeon plans to prevent bulges or bumps at the ends of the scars and extra tissue under the arms, known as “dog ears”
- whether certain anatomical features, such as large breasts, weight, or body type, can make flat closure challenging, and how the surgeon will address these challenges
- what to expect during recovery and what realistic results could look like
It is up to each person to decide whether and how much they want to discuss their decision to go flat with their loved ones.
Some people may benefit from considering these factors in advance:
- who they want to tell
- how they want to share the message, such as in person or over the phone
- which details they want to share
- how they will explain which topics or questions are off-limits
Some may also have concerns about sex after going flat. Seeking guidance from a sexual health therapist who works with people with breast cancer can help a person navigate conversations about sex in relation to going flat.
During an aesthetic flat closure procedure, the surgeon removes extra skin, pockets of fat, or excess tissue. They tighten and smooth out the tissue that remains to form a flat chest wall contour. If a person has opted for an immediate flat closure, they may need a second procedure to reduce the scooped-out shape or to smooth indentations.
Breast surgeons may be able to perform the procedure at the same time as a mastectomy. However, in some cases, a person may have better results if a plastic surgeon carries out the reconstruction. This may be the case if:
- they have a higher body mass index and therefore a greater amount of skin and fat to remove
- they have a larger breast size and therefore more breast tissue to remove
- the tumor is at the base of the breast and near the chest, rather than in the outer breast tissue and closer to the nipple
- radiation therapy before or after a mastectomy affects the skin and tissue quality
- completely removing the inframammary fold, which is the natural lower edge of the breast
- ensuring the same flap thickness on both sides
- removing the right amount of fat to allow for a smooth chest contour
- preventing “dog ears” of skin under the arms by carefully removing tissue
Most patients will have drainage tubes under the skin for 1–2 weeks and will need to empty them and record the output.
After a mastectomy and an aesthetic flat closure, people take an average of 3–4 weeks to recover. However, recovery time for some people can be 6–8 weeks.
Compared with breast reconstruction, going flat after mastectomy tends to involve a shorter recovery time, less discomfort, and a lower risk of complications.
Support groups in the United States can help people to picture what going flat could look like, and mean, for them. Two of the available online advocacy and support groups are:
Besides information on the procedure itself, these groups provide resources such as photo galleries and videos showing the experience of other people who have gone flat.
Social media support groups also provide spaces for people to share their experiences.
While most people choose to have breast reconstruction after a mastectomy, others choose to go flat.
There are many reasons someone may choose not to have their breasts reconstructed. They may wish to avoid the extra recovery time, the cost of the procedure, or the potential complications of reconstruction.
The procedure involves removing excess skin, tissue, and pockets of fat and tightening and smoothing the tissue that is left to form a flat chest wall. Recovery from this procedure usually takes 3–4 weeks, which is shorter than the recovery time for breast reconstruction.
A person may or may not choose to talk with their loved ones about their experience. They may also seek support from some of the available social media and online support and advocacy groups.