Your guide to ‘going flat’ after breast cancer

For some women, breast reconstruction can be a positive time where they feel like they’ve ‘closed the loop’ on breast cancer treatment. Others don’t feel the need to undergo reconstruction and are happy to ‘go flat’. While both are equally valid options, in this blog, we’ll take a look at what going flat means and why many women prefer it.

A recent study surveyed 931 women who had undergone either a uni- or bilateral mastectomy (had one or both breasts removed) with no reconstruction. Of those, 74% were satisfied with their outcome, and named several reasons for going flat, including:

• Wanting a faster recovery
• Avoiding an implant
• Believing that breast reconstruction wasn’t important for their body image.

The study may not be representative of all women in the breast cancer community, as it was distributed via social media and blogs to the ‘go flat’ community. But it is a positive result, and researchers are working with surgeons and patient advocates to develop a survey for the broader patient population.

When women talk about ‘going flat’, it usually refers to ‘flat closure’ or ‘aesthetic flat closure’, where the chest wall is reconstructed to be smooth and flat after mastectomy or at explant (surgery to remove a breast implant). This involves removing any excess tissue after the breast tissue is removed and can also involve contouring the remaining tissues to create a flat appearance. In what can be seen as a mark of recognition, The National Cancer Institute in the US added the term ‘aesthetic flat closure’ to their official Dictionary of Cancer Terms in 2020.

So what should you know if you’re considering ‘going flat’?

Be clear about what you want

Unfortunately, 22% of the women in the above study reported experiencing ‘flat denial’. That is, flat closure wasn’t offered to them at first, or their surgeon didn’t support their decision or left additional skin in case the patient chose to have future breast reconstruction. If you have decided to go flat, you can seek a second opinion if your surgeon tries to talk you out of your choice or you don’t feel comfortable. When you find a surgeon you like with, tell them that you want an “aesthetic flat closure”, that is, a smooth, flat chest. You may also like to discuss the below points with your surgeon:

Have they performed aesthetic flat closures before? Can they show you photos of their work?

How many surgeries will be needed to get the best cosmetic result?

What will they do if there are concave areas on the chest? Can this be fixed with fat grafting?

How will they avoid ‘dog ears’ or ‘tabs’ of skin? How will they account for gravity?

What can they do if you have very large breasts or are overweight?

Where will the scars be after the surgery? (This is especially important if you plan to cover the scars with a tattoo once they’re healed.)

Prepare for an adjustment period

Coming to terms with the loss of your breasts due to breast cancer can take some time, and ‘going flat’ may take come with some extra adjustments. There are plenty of resources and support for those who choose to go flat, from support groups to exploring ‘flat fashion’ to being comfortable with the changes to your body. Not Putting on a Shirt has a comprehensive guide to ‘living flat’ and you can also join our online community, mybc, to share your experience and ask for advice.

It’s okay to change your mind

Some women choose to go flat later on for many reasons, including being unhappy with their reconstructed breast, wanting to remove implants or for medical reasons. And some women who choose to go flat after mastectomy end up considering reconstruction later on – this is still possible after flat closure, without needing to leave extra skin. Others who go flat may also prefer to wear breast prostheses, to restore the appearance of having breasts when clothed. Your medical team can talk through your options, or you may like to consider counselling. BCFNZ funds three free counselling sessions with qualified counsellors around the country, and you can apply online or contact our nurses on 0800 226 8773 or email breastnurse@bcf.org.nz