More Breast Cancer Patients Opting Out of Reconstructive Surgery - Verywell Health

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Key Takeaways

• More breast cancer patients are choosing a flat chest wall closure after a single or double mastectomy
• Some breast cancer patients are not offered the option of forgoing breast reconstruction
• Many patients who choose to "go flat" are happy with their decision

A recent study by the UCLA Jonsson Comprehensive Cancer Center has found that an increasing number of breast cancer patients are declining reconstructive breast mound surgery after mastectomy and choosing to "go flat" instead.

Lead researcher Deanna Attai, MD told Verywell that she wanted to conduct the study because she noticed that modern surgical literature's claims about breast reconstruction after mastectomy did not necessarily match the voices of breast cancer patients in online communities.

"A lot of the surgical literature actually shows that patients who go flat are not as satisfied as those who have reconstruction," Attai says. "But I was seeing a disconnect in the online patient communities and the going flat communities where these were women that were saying this was the best decision they had ever made. They are there supporting others."

For the study, her team surveyed 931 women who had "gone flat"— either because it was their personal choice or because there was a medical reason that a breast reconstruction would not be possible.

The survey indicated that most of the patients were happy with their decision not to have breast reconstruction.

"Flat Denial"

Attai said that 22% of the patients surveyed experienced "flat denial" where they were not even given the option to forgo reconstruction. In these cases, a surgeon might have done one or more of the following:

• Refused to present a flat chest wall closure as an option
• Did not support a patient's decision to go flat
• Intentionally left excess skin against the wishes of the patient in case the patient changed their mind

Patient Experiences

Tanice Kitchener, PT, DPT, told Verywell that she initially chose reconstructive surgery when she had a preventative double mastectomy because of a history of lung cancer and detection of the BRCA1 gene. She was 28 when she had the surgery.

Tanice Kitchener, PT, DPT

After having the implants, I just realized, this is still not my body.

— Tanice Kitchener, PT, DPT

"At the time, I didn't consider going flat. I hadn't met anyone that had done that as a 28-year-old and it seemed kind of extreme," says Kitchener. "After having the implants, I just realized, this is still not my body."

Kitchener's initial dissatisfaction with her implants—which included the fact that they were larger than she had requested—began when one of them flipped within the first year and required surgery to correct.

Her active lifestyle was limited because she had to be careful to avoid rupture or flipping again. In 2019, she found that despite her best efforts, her implants had indeed ruptured. After fighting to get the MRI that revealed the ruptures, she found that the implants had been recalled—but she had never been notified.

Tanice Kitchener, PT, DPT

I talked to four different surgeons. And each one of them tried to convince me that if I went flat, I would be disfigured and very unhappy.

— Tanice Kitchener, PT, DPT

Instead of replacing the implants, at age 36, she decided that she was done. "I didn't want to go flat, but I wanted less to have more surgery and have implants in my body that could potentially be dangerous," says Kitchener. "So my husband and I talked about it, I met with the surgeons, and luckily I had time on my side. I had some time to think about it, and analyze my priorities, and frankly, start to try to visualize myself flat and see how that felt."

Finding a surgeon willing to perform what would hopefully be the last of her surgeries was difficult. "I actually went and talked to four different surgeons. And each one of them tried to convince me that if I went flat, I would be disfigured and very unhappy," Kitchener says.

As a member of the medical community, Kitchener knew how to advocate for herself and fought for what she wanted. Still, even as she was being wheeled into surgery, her female surgeon was incredulous that she wanted to continue with a flat closure.

Devorah Vester told Verywell that her experience requesting a flat chest wall closure was very different. After she was diagnosed with ductal carcinoma in situ (DCIS), her oncologist recommended a lumpectomy. After completing the proscribed surgery, her sister was also diagnosed with DCIS.

According to Attai's study, 74% of respondents were happy with their decision to "go flat."

Despite lacking the BRCA1 gene, because of her familial history, doctors monitored Vester's situation closely. A year later, Vester was diagnosed with stage one breast cancer. She decided to immediately to have a double mastectomy. Reconstruction was never a consideration.

"It's just not who I am," Vester says. "For me, I enjoyed my breasts for many years. I have a grown child, I'm not having babies anymore. I just didn't feel the need to have anything foreign in my body."

Devorah Vester

I was extremely pleased and ecstatic that my doctor's goal was to do what I wanted to do and give me the information to make an informed decision.

— Devorah Vester

Attai's study found that the attitude of the surgeon plays a significant role in the overall satisfaction of the patient. Surgeon support for the surgery was one of the strongest predictors of overall satisfaction. When surgeons opposed the decision, satisfaction levels were lower.

Vester said that she did take some time to mourn the loss of her breasts but that ultimately, the decision was simple for her. Luckily, her oncologist supported her decision.

"I was extremely pleased and ecstatic that my doctor's goal was to do what I wanted to do and give me the information to make an informed decision," Vester says. "He spent a couple of hours with me and the army of note-taking friends that I brought with me and gave me all the facts that I needed."

Unhappy Patients: Weight Can Play a Role

Having a higher BMI was one of the greatest indicators among patients who were not happy with the decision to go flat. Attai suggests this could be because a satisfactory surgical result can be difficult to produce in overweight or obese patients.

"From a technical standpoint, it's a lot easier to give a neat and tidy chest wall closure to someone with a smaller breast," says Attai. "For someone who is overweight or obese, there's more excess skin and fat rolls, so it's a lot harder to achieve a flat closure, but it can certainly be done."

Attai adds that for breast cancer patients with a higher BMI, a flat chest wall closure may take more than one surgery to receive the desired effect.

What This Means For You

Patients with breast cancer or those who have a preventative mastectomy may have the option of forgoing reconstructive surgery. Many patients who decide not to have breast reconstruction are happy with their decision.

If you are trying to decide whether or not to "go flat," talk to your oncologist and surgeon.

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