After a mastectomy, some women don’t want to replace their breasts

Several of those who have requested the procedure say they were rebuffed – and outright refused – by their doctors when told about it

(Jimena Estíbaliz for The Washington Post)

During her training as a breast surgeon, Deanna Attai, an associate professor at UCLA’s David Geffen School of Medicine, read studies and heard from mentors that women who opted against breast reconstruction after mastectomy had generally a lower quality of life.

But Attai found it didn’t match what she’d seen online over the past few years: Facebook groups with names like “No Shirts” and “Flat and Fabulous” that included several hundred happy stories from women — and photos — about their choice to have “aesthetic flat closure,” the term used by the National Cancer Institute as of 2020, and forego breast reconstruction.

Attai therefore did its own survey of nearly 1,000 women who had undergone single or double mastectomy without reconstruction. Published last year in Annals of Surgical Oncology, it found nearly three-quarters of women said they were satisfied with the outcome.

No government or organization tracks the number of apartment closures each year. According to the National Breast Cancer Foundation, nearly 277,000 cases of invasive breast cancer occurred in 2020 in the United States. The American Society of Plastic Surgeons reported that about 140,000 mastectomies were performed that year, about half of which involved additional reconstructive surgery.

The flat closure has always been an option, but Anne Marie Champagne, a Yale doctoral student whose research focuses on this issue, says there has been a shift in attitude towards flat closures in conversations online from 2012. Champagne, 53, who opted for flat closure after a mastectomy in 2009, says that before 2012, there were only two posts about flat closure on the message board . “That year, I saw a message from the founder of the advocacy group Flat Closure NOW! that read, I want to see you. I want to form a union. I wish it was okay to be flat… if it’s your choice, I hope women who see me, as flat as possible, will see that the reconstruction is not normal.

What struck Champagne was not just the content of the message, but the number of people who read it. “At most, posts have been viewed a few thousand times,” Champagne says. “[That] post had 79,000 views and 3,500 comments within six months of posting.

My double mastectomy made me reevaluate: what do my breasts mean to me?

While many women still opt for breast reconstruction, as figures from the American Society of Plastic Surgeons clearly show, Champagne and others committed to the issue of flat closure tick off a list of reasons, including a increased awareness of the option, for what cancer doctors and surgeons say there is growing interest in going flat.

“I’ve definitely seen more patients ask to be flat after a mastectomy, probably because they feel more empowered to make that decision,” says Roshni Rao, chief of breast surgery at Columbia University Medical Center in New York. .

“A diagnosis of breast cancer can be especially overwhelming because there are so many decisions to make in a short time, including choosing doctors, a treatment plan, and a woman’s post-mastectomy breast,” says Attai, in an email. There is more awareness now that the reconstruction process carries risks. “Women who opt for reconstruction, whether it’s a breast implant or their own tissue (called autologous reconstruction) could face multiple surgeries, post-operative recovery, risk of 10% infection that can interfere with a chemotherapy or radiotherapy program, and occasionally recalls and implant removals.”

For women who want to do reconstruction, Attai says, they often think the effort and the risk are worth it. “But for others, it’s not.”

It wasn’t for Pepper Segal of North Carolina, who was diagnosed with breast cancer three years ago while pregnant at age 31. She was delivered at 36 weeks and started chemotherapy two weeks later. But soon after, she felt pain in her armpit which turned out to be the spread of cancer. Segal underwent an emergency mastectomy and decided to remove both breasts – and have a flat closure.

“I was told that if I wanted to have reconstruction I would have to wait two years because my form of cancer has a high recurrence rate and detection can be more difficult with implants or autologous reconstruction,” she says. . “But I opted for the flat closure. I didn’t want to subject my body to anything else.

Segal says she “thank God for Billie Eilish” and her signature baggy clothes. “I can dress in loose clothes, and it looks cool now.”

Expectations have changed

Sagit Meshulam-Derazon, a plastic surgeon at Rabin Medical Center in Tel Aviv who specializes in breast reconstruction, says she and her medical partner, who is also a plastic surgeon, recently discussed the choice they would each make if they received a breast cancer diagnosis. The two agreed that they would opt for a flat closure, noting that expectations for how a woman should look had changed a lot.

“Look at Andie MacDowell, the actress, who now plays roles without coloring her gray hair,” Meshulam-Derazon says. “What women look like these days is more often what they choose to look like, rather than an idealized image.”

Transgender woman challenges Chicago definition of female breast

Champagne also says she thinks online photos of post-mastectomy flat chests of transitioning transgender men played a role.

“I had several friends who transitioned in the years leading up to my diagnosis and surgery, and saw what their flat chests looked like, which made me feel like I had more options. “, she says. “Socieally, we have become more open to a wider range of bodily expressions.”

However, the women in Attai’s survey, as well as posts on the social media pages of apartment closure advocacy groups, find that some women are rebuffed and outright denied by their doctors when they bring up the idea of ​​closing apartments or say that is what they want. They want.

Some 22% of women who responded to Attai said that a flat closure option was not initially offered by their surgeon, or was not supported by the surgeon, or that the surgeon intentionally left out the extra skin in case the patient changes her mind. This extra skin would require further surgery if the woman did not change her mind about flat closure.

“I did you a favor,” was what Champagne’s doctor told him when he entered his hospital room after the mastectomy to explain that he had left extra skin for reconstruction.

“Even though I went into surgery thinking we agreed on closure,” Champagne says. “I had clearly expressed my wishes. To this, he replied that, in his experience, all breast cancer survivors recover in six months. When I heard his words, I felt deep grief, a combination of grief and anger. I couldn’t believe my surgeon would make a decision for me while I was under anesthesia that would go against everything we had discussed – what I had consented to.

She is not currently considering revision surgery to remove excess skin.

Kim Bowles, 41, of Pittsburgh, says her surgeon’s decision to ignore her stated decision to have a flat closure is what galvanized her to start the advocacy group Not Putting on a Shirt. “When the anesthesia started to kick in, I heard the surgeon say he was going to leave some skin in case I changed my mind, and it was too late for me to protest. I woke up with a look that I didn’t want,” she said.

Now, the organization’s website includes a list of plastic surgeons who perform aesthetic flat closures and provides talking points for patients to help them discuss the procedure with their doctors. Bowles underwent revision surgery three years after his initial operation.

Not an option for everyone

Not everyone can or wants to have a flat closure. Kelsey Larson, chief of breast surgery at the University of Kansas Health System, says it’s important for patients to consider first and foremost how any surgical choice may affect their cancer treatment and outcomes. cancer.

“It’s very important for patients to remember that they are having a mastectomy for medical purposes, as part of the prevention or treatment of cancer,” she says. Larson says she would “encourage any patient receiving cancer care to ask questions” specifically about these issues.

Years ago when my twin had breast cancer I took drastic action and I’m grateful I did.

Elizabeth Mittendorf, chair of surgical oncology at Harvard’s Brigham & Women’s Hospital in Boston, and Susan G. Komen Foundation fellow, says heavier patients especially need to talk to a plastic surgeon, rather than to a general surgeon, before opting for a flat closure procedure, and be prepared that the look may not be what you hoped for.

Excess fabric in women who carry more weight often means it’s not possible to achieve a sleek, flat look, says Mittendorf. And it may take more than one surgery to allow parts of the woman’s body to heal before completing the procedure.

Larson says that while she welcomes the increased focus on flat closure so women can choose the option they want, she is concerned that women who want breast reconstruction after mastectomy now feel hesitant.

“In recent years, patients have whispered to me that they want reconstruction,” she says, “they fear they will be misjudged for choosing breasts.”

In a sign of the growing interest in flat closure, sessions on how to communicate about it with patients are springing up at medical meetings about breast cancer. Attai and defenders such as Bowles have been asked to give presentations.

That’s important, says Scott Kurtzman, chief of surgery at Waterbury Hospital in Connecticut and president of the National Breast Center Accreditation Program (NAPBC), a program of the American College of Surgeons.

“I’m sure there are a lot of surgeons out there who have their own idea of ​​what female aesthetics should be, and they struggle to release it and accommodate people who don’t share the same point of view. view,” Kurtzman says.

NAPBC is now asking breast centers to report to the board of directors on how they share decision-making on post-mastectomy choices and to demonstrate that they accept patient requests for aesthetics that a patient chooses.

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