Choosing Between Reconstruction and 'Going Flat' After Breast Cancer

A breast cancer diagnosis is overwhelming. Not only are you processing the fact that you have a life-threatening disease, but you're also facing a multitude of treatment decisions. For many women, those include having a mastectomy and dealing with the difficult emotions that surface when thinking about the loss of one or both of your breasts. While breast reconstruction has become the standard of care and a way to help many women "feel whole" again, it should never be assumed that it's the best option for every woman. The decision to have or not have breast reconstruction should be carefully considered. It's important to take the time necessary to gather the information you need and weigh the pros and cons of reconstruction versus "going flat." Unfortunately, 70 percent of women feel they're not fully informed about their reconstruction options prior to having a mastectomy.

Women should also never assume their initial gut response (to go flat or have reconstruction) is going to be their final choice. It is a process that takes time and involves asking questions, doing some soul-searching and seeking out information to help you with this very personal decision. I have learned from experience that there is no way to predict the choice a patient will make. While one might expect a young single woman to opt for reconstruction and an elderly married woman would not, sometimes the opposite is true.

[See: 10 Ways to Prepare for Surgery.]

Medical Considerations

Breast reconstruction can be a daunting and complicated process that requires a number of additional medical interventions following the main surgery and can substantially lengthen your recovery time if done immediately after a mastectomy. It can also raise the risk of infection and other complications. And, depending on the type of surgery you have, it can sometimes alter muscle function. However, some of the newer reconstruction methods minimize that risk.

There are several different types of reconstructive procedures so it's important to discuss these various methods with your breast cancer surgeon and a plastic surgeon who specializes in breast reconstruction, to fully understand the number and duration of surgeries and additional procedures involved, the length of time required for reconstruction and recovery, and the likely results and potential risks. It's also helpful to look at photos and videos and talk to other women who have undergone reconstruction or have chosen to go flat to get a more realistic sense of what to expect. If you decide to proceed with reconstruction, make sure your plastic surgeon has expertise in the type of reconstruction you choose -- some surgeons specialize in a specific method. If you opt for going flat, your breast surgeon can perform the mastectomy with a flat incision. (No plastic surgeon is involved since there is no reconstruction.) Choose a surgeon who has done the same surgery for other patients. It's also helpful to show the physician pictures of women who went flat with the results you like, while emphasizing your desire for an incision that looks good, lies flat, is comfortable and does not interfere with regular daily activities.

If you have diabetes, circulatory problems, a bleeding disorder or are an active smoker or drinker, you may not be a good candidate for breast reconstruction, since those factors affect your ability to heal.

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Appearance and Sexual Considerations

Natural breasts are more important to some women than others. After breast removal, the value of reconstructed breasts also varies substantially between women. There are women who may see reconstruction as necessary to restore their sense of self, to maintain a "normal" appearance or an opportunity to have the breasts they've always dreamed of. For others, reconstructed breasts that lack sensation may not be worth the additional surgeries and potential complications that come with reconstruction. In deciding which way to go -- reconstruction or breast-free -- you should consider the appearance and sexual implications of each choice and what's most important to you.

A reconstructed breast will never look and feel the same as your original. In many cases, the nipple cannot be preserved, so the choices include going without a nipple, having a nipple rebuilt from surrounding skin and/or having a 3-D nipple tattoo -- an option that has become quite popular because of how real it can look. There is usually no normal sensation in the breast and nipple after reconstruction. But for many women, reconstructed breasts help them feel more normal and familiar in the way they look in and out of their clothing.

Going flat, on the other hand, is a dramatic change. Some women find it a liberating and empowering choice. But there is also the possibility that you may not be comfortable with your appearance. Women who have large breasts or are overweight can end up with "dog ears," which are pockets or tufts of extra skin and fat at the ends of the mastectomy incision. A big belly can become much more noticeable in women who decide to go flat. It may require a new approach to your wardrobe if you don't want to look lopsided or don't want to draw attention to being flat. Some women embrace this style change and the chance to get creative, while others may find it daunting.

Using a breast form known as a prosthetic that is slipped into a bra or bathing suit pocket can be a solution for those who choose no reconstruction but want to maintain the look of having breasts. However, some women find them annoying and uncomfortable to use. It is also possible that if you change your mind about being breast-free, you can have reconstruction at a future date, although the cosmetic results are usually better if it's done at the time of your mastectomy.

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If you're in a relationship, your partner may also have feelings about your choice. It's a good idea to hear how he or she feels and thinks about breast reconstruction before surgery. Still, the decision is yours. No matter which choice you make, sex will likely be different after a mastectomy. That doesn't mean it can't be just as fulfilling, but it may require some exploration and experimentation to figure out what works best for you and your partner.

When considering going flat or having reconstruction, ask your doctor for a full and balanced discussion of both options. If your interest in going flat is not being taken seriously or supported by your surgeon, find another surgeon who will listen and provide you the information you need to help make this big decision. What's most important is that you carefully weigh your options and make the choice that's right for you.

Marisa C. Weiss, M.D. is the founder, chief medical officer and guiding force behind Breastcancer.org, the world's most utilized resource for expert medical and personal information on breast health and breast cancer -- reaching 72 million people globally since it was founded in 1999. Dr. Weiss currently practices at Lankenau Medical Center in Wynnewood, Pennsylvania, where she serves as director of breast radiation oncology and director of breast health outreach. A breast oncologist with more than 30 years of active practice in the Philadelphia region, Dr. Weiss is regarded as a visionary advocate for her innovative and steadfast approach to informing and empowering individuals to protect their breast health and overcome the challenges of breast cancer. Dr. Weiss serves on the Center for Disease Control and Prevention's Advisory Committee on Breast Cancer in Young Women, and she's the author of four critically acclaimed books on breast cancer and breast health.