Reasons people stay flat after mastectomy

There are many reasons people decide not to have reconstruction surgery after a mastectomy. The choice to stay flat is never 'right' or 'wrong'. Some people find the decision easy and are just happy to stay flat. Others make their decision after a lot of thought, discussion and research.
What's important is:

• you're comfortable with how your body looks and feels
• you have the information you feel you need to make your decision.

In this article, we share some of the factors that can help in making your decision.

The thought of more surgery

Having a reconstruction often requires more than 1 operation after a mastectomy.

You may decide to stay flat because:

• you’ve have had enough of hospitals and surgeries
• the potential risks and side effects of more medical procedures are not worth it to you
• you’re concerned you may not be happy with the result of implant or flap reconstruction
• you have other health issues (like diabetes or heart disease), so more surgeries may not be the best decision for you
• your personal situation, such as caring responsibilities, finances or how far you have to travel for surgery.

Some people need time after a single mastectomy to feel confident the cancer is not in their other ('contralateral') breast, before they can think about more surgery.

How the chest or breast(s) may look and feel

Breast reconstruction surgery won’t give you back your breast or breasts. Even if you have reconstructive surgery, the result may not look or feel natural for you, in particular with implants.

Some people prefer the result they achieve with aesthetic flat closure. This choice still gives you options such as:

• the type or shape of closure
• nipple reconstruction
• nipple tattoos
• temporary or permanent breast prostheses - such as fabric or silicon bra inserts that simulate the shape and sometimes the weight of your breast.

Depending on your surgery, you may not have the same level of sensation in the skin or nipple. This is possible whether you stay flat or have reconstruction.

If reconstruction using your own tissue is not possible, implant reconstruction is an option. But you may decide you don't want a foreign object (breast implant) in your body.
You may also consider an external breast prosthesis. This is a silicon form that you wear in your bra to simulate the shape and weight of your breast.

You might choose to wear a prosthesis all the time or only sometimes. Some people choose not to, finding it hot, uncomfortable, heavy and awkward.

Personal beliefs and self-image

The presence, size and shape of breasts has different meaning for different people. The choice to go flat may challenge traditional or cultural ideas around breasts. This can lead to you feeling pressure, from family, friends, your healthcare team and society in general.

Your personal beliefs and self-image are an important factor.

You may like to think about what your breasts mean for you. You might feel they are important for their appearance, the way they feel, or for their function, such as breastfeeding.

For some, their breasts have been a very important part of who they are, their sexuality and desirability. For others, their breasts are not important to their body image or how desirable they feel.

Whatever you choose, symmetry and ‘feeling normal’ can have psychological benefits.

In the BCNA podcast episode The mirror image: body image difficulties, Dr Charlotte Tottman talks about:

• her experience of the changes to her body as a result of cancer treatment
• how the changes to our physical form can challenge our sense of self, identity and who we are.

Breast size and body shape

A smaller difference between ‘before’ and ‘after’ can make us feel more comfortable.

People who have previously had larger breasts often say they prefer reconstruction. Going flat is too big a change for them.
For people with smaller breasts, going flat is often not a big physical change and is sometimes easier to accept.

You may need to consider the physical effects of your decision, such as back problems. For example:

• Staying flat after single ('unilateral') mastectomy can mean your weight is not even on both sides. This lack of symmetry can affect the spine and is a greater risk for people with large breasts or previous spinal problems. Breast prostheses usually do not match the weight of natural breast tissue.
• A double ('bilateral') mastectomy can affect posture. People may not stand up straight, instead standing in a way that 'protects' their chest area. People can overcome this risk with awareness and conscious effort. Sometimes they need physiotherapy support.

Life stage and daily activities

Some people may feel too young not to have breasts, while others are less concerned.

If you are planning on having a baby after your treatment, ask your surgeon whether breastfeeding would be possible if you had your breast(s) reconstructed. If you are no longer breastfeeding, your breasts may not be as important.

For some people, their decisions may be influenced by:

• the type of work they do
• activities and hobbies, such as sport, gardening, or playing a musical instrument
• comfort, such as their posture (equal weight across the chest)

Impact on family, work or finances

It may not be practical or possible for you to choose reconstruction because of:

• the impact on your job or study – needing more time off work to recover
• family needs and expectations – looking after children, having carer responsibilities, needing to drive
• additional costs – out of pocket costs even if you have private health insurance
• your location – travelling long distances for surgery and follow-up care if you live in a rural or remote area.

Fear of cancer coming back

When you have breast cancer surgery, nipple-sparing or tissue-sparing mastectomy are sometimes offered. These options make it easier if you plan to have breast reconstruction later. However, there is a small risk of cancer coming back (‘recurring’) in the remaining breast tissue.

A concern about cancer returning can influence people’s choice to stay flat.

Other people’s opinions and experiences

You may feel that this decision between reconstruction and staying flat is yours alone. Or you may want to know what the people who are important to you think.

Deciding to stay flat is related to what's important to you. When our choices match our priorities, we do better psychologically, so it’s important you are comfortable with what you decide.

The decision should reflect what you want, not the opinions of others, including doctors and loved ones.