Discussions about whether women should have breast reconstruction after mastectomy are like politics: everyone has an opinion. Wander around the Internet and you’ll find blogs against reconstruction, arguing why women should stay flat after mastectomy. You’ll also find the polar opposite view: strongly-worded positions in favor of breast reconstruction.
We are all different.
We all have our own goals, varying likes and dislikes, and decidedly personal opinions of what is right for each of us. Some of us feel that the breast reconstruction journey is well worth the effort, and that is just fine. Others consider it a risky waste of time and effort, and that is also fine, because what is right for one isn’t necessarily right for all.
"Going flat" isn’t right or wrong. It’s a personal choice. You may have many reasons why you don't want to have reconstruction. Maybe you:
The goal of mastectomy is always to remove as much breast tissue as possible, whether you do or don't have reconstruction.
If you don’t have immediate reconstruction (at the same time as your mastectomy), your surgeon will make a broad elliptical incision across your chest, remove the tumor (if you have one), breast tissue and excess breast skin, including your nipple and areola, and any previous biopsy scars. The edges of skin on either side of the incision will then be pulled together and closed.
Before your surgery, it’s important to speak with your surgeon about how your incision will be made and how your chest will look after your mastectomy. Ask about an "aesthetic flat closure." This means that excess skin and fat in the chest will be removed, leaving a smooth, tightened, and flat surface.
If you change your mind about reconstruction, your breasts can be recreated at any time in the future. Your mastectomy scar, will remain on your new breast, although it will fade considerably in time. Either way, the choice is yours.
want the simplest and fastest recovery possible after mastectomy
don’t want breasts that aren’t “real” and have little or no feeling
don’t consider a flat chest to be a significant change from your natural breasts
fear the potential reconstructive complications or unsatisfactory results
want to try going flat before committing to breast reconstruction
are unsure about reconstruction at the time of your mastectomy
have a health condition or pending treatment that precludes having reconstruction
Mastectomy without reconstruction is performed through a broad elliptical incision across the breast.
My scars sometimes attract my attention when I look in the mirror—often I just see me. No one has ever commented about noticing that I go flat. I wouldn’t have done anything differently.—Margaret
The Goldilocks mastectomy
Some breast surgeons offer a Goldilocks mastectomy for women who don’t want breast reconstruction but prefer not to be completely flat. In this procedure, a small mound is fashioned on the chest using fat under the breast skin that remains after breast tissue is removed. Results tend to be better for patients with very large breasts. However, it can sometimes be difficult, if not impossible, for surgeons to tell where the breast tissue ends and the fatty tissue begins. No large studies have identified appropriate candidates for whom this procedure can be performed predictably and safely.
Not all surgeons perform this procedure, so be sure to discuss this possibility during your consultation.
After bilateral mastectomy, you may prefer to remain flat under your clothes or wear breast prostheses, breast-shaped forms that temporarily adhere to your chest or fit into the pockets of special bras, lingerie, swimsuits, and camisoles to temporarily restore shape and profile.
If both of your breasts are removed, your new “breast” size is limited only by the prostheses you choose. Unilateral mastectomy presents a more practical problem. Because one breast is missing, you may feel unbalanced or lopsided and find it difficult to fit into clothes. When you’re dressed, one side of your chest will be flat; if you wear a bra, one cup will be empty.
You can balance your remaining breast and regain symmetry with a weighted prosthesis that will provide balance and help you to maintain proper posture. (Weighted prostheses aren’t necessary after bilateral mastectomy because your chest, although flat, is balanced.) If you’re undecided about reconstruction or you need to delay it until you’ve completed your post-mastectomy treatment, a prosthesis can also serve as a temporary breast during the in-between interval.
If you contact Reach to Recovery (www.cancer.org; search for “Reach to Recovery”) several weeks before your mastectomy, a volunteer will bring a lightweight starter prosthesis and a mastectomy camisole or bra to the hospital and show you how to use them.
When your mastectomy scar heals sufficiently—generally in about four to six weeks—your surgeon will give you a prescription for mastectomy bras and more balanced, better-designed prostheses. Be sure to get a written prescription; otherwise, your health insurance may not cover the cost. It’s a good idea to be measured by a qualified fitter—one who is certified by the American Board for Certification in Orthotics, Prosthetics, and Pedorthics—for your first postmastectomy bra and prosthesis to ensure it fits properly on your chest and isn’t too light or too heavy. Try on different styles to see which ones look and feel the best.
Teardrop prostheses add extra fullness at the bottom (left).
Triangular prostheses fill in missing tissue at the sides and top of the breast (center). Some prostheses are adjustable (right).
Images courtesy of Amoena USA Corporation.