Mastectomies are breast-removal surgeries used to treat breast cancer. For many patients, it’s followed by breast reconstruction surgery.  However, some skip the second procedure and “go flat”. That’s what Shay Sharpe decided at age 36 during her second round of breast cancer. During her first bout at age 26, she underwent a double mastectomy and breast reconstruction with implants. However, her body rejected the left implant as a result of her radiation treatment. The left breast was reconstructed using fat from her thigh. But when the cancer reappeared in the same spot, she once again had to make a choice.
“I was like, ‘I’m done with this, I’m not doing anything else. Instead of reconstruction, let’s just remove the right one’. And the doctors were like, ‘What are you talking about?’” Shay said. “…On the day of the surgery, my doctor told me I was the only person with insurance who had ever gone flat. He asked, ‘Do you know what you’re doing?’ He looked at my mother and my ex and asked, ‘Did she discuss this with the two of you? Once she’s flat, that’s it.’ I was sitting right there! I told him this is what I want, it’s my choice. I was just over it.” 
“Going Flat” After Mastectomies
For many breast cancer survivors facing mastectomies, they never even heard of the option to go flat. Many who choose it, like Shay, face opposition from their surgeon. Women may opt-out of breast reconstruction for many reasons, but the common ones include not wanting a foreign object implanted into their body, and wanting a lower risk of surgery complications and other potential health concerns.
A 2021 study by the UCLA Jonsson Comprehensive Cancer Center found that an increasing amount of breast cancer patients are going flat after their mastectomies. Lead researcher Deanna Attai, MD explained that she noticed a discrepancy between surgical literature’s claims about breast reconstruction and the claims of breast cancer survivors in communities online.
“A lot of the surgical literature actually shows that patients who go flat are not as satisfied as those who have reconstruction,” Attai said. “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.”
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So she and her team surveyed 931 women who had gone flat as a personal preference or because of medical reasons that prohibited them from breast reconstruction. The results showed 74% were satisfied with the results of their procedure and happy with their choice to forgo breast reconstruction. However, 22% faced what the community calls “flat denial” where their surgeon refuses to present going flat as a viable option after mastectomies, or they don’t support their patients’ decision to go flat. Some surgeons even kept excess skin “in case the patient changed their mind,” completely violating the wishes of the patient. 
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Choosing an “Aesthetic Flat Closure”
To avoid this scenario, Attai advises other breast cancer patients to be very clear with their decision. “I think the best women can do is be completely up front with their surgeon,” she advised. “Bring in pictures if possible… If there is a clear violation of what was agreed upon, there should be a clear explanation of why and attempts made to resolve the situation — but unfortunately that requires another surgery… If the surgeon just does not support the patient preoperatively, I would recommend a second opinion if possible. Trust is important, and surgeon support of the patient’s decision was one of the factors most associated with patient satisfaction.” 
Also, you may want to find a surgeon who has experience doing “aesthetic flat closure,” which is the term used for when the procedure removes extra skin, tissue and fat, to leave the chest area looking smooth. “A woman who opts for no reconstruction still wants a neat/tidy appearance to the chest wall and surgeons need to become proficient with the techniques needed to achieve this, just as they have become proficient at removing the breast,” Attai said. “…One of our hopes is that going forward, when a woman says she wants to go flat or forgo breast mound reconstruction, that the surgeon understands what the patient really wants is an aesthetic chest wall closure.”