Why I Chose To Remain Flat After My Mastectomy

When I was diagnosed with breast cancer in 2022, I reacted the way most women do: with shock, confusion and fear. I also needed to make fast decisions about my body. Faced with the reality that I would need to undergo a double mastectomy, I had to quickly research and decide on what reconstruction option would be best for me—and I eventually decided to choose an aesthetic flat closure. Here's why.

The most common types of breast reconstruction

There are two typical forms of breast mound reconstruction: Breast implants and tissue reconstruction.

Implants, filled with either silicone gel or saline, are inserted under the skin and chest muscles to mimic breasts. Today’s implants last between 10 to 15 years, meaning they will likely need to be replaced during the course of one's life.

Tissue reconstruction transfers fat, blood vessels, skin and sometimes muscle from the abdomen or back to form a new breast.

Breast implants typically require two surgeries, while tissue reconstruction usually only requires one. Both procedures come with risks, including blood clots, seroma (abnormal accumulation of fluid), capsular contraction (when scar tissue forms around an implant) and skin necrosis (tissue death). Recovery times for each surgery can range from six to eight weeks.

The use of radiation, which was part of my own breast cancer treatment, also can also complicate future  reconstruction.

“Radiation can impact the timing for breast reconstruction as well as the techniques used for reconstruction,” says Dr. Toni Zhong, director of the University Health Network (UHN) Breast Reconstruction Program in Toronto as well as the Belinda Stronach Chair of UHN Breast Reconstructive Surgery.

“Generally plastic surgeons like to wait months to even over a year before carrying out any form of reconstruction in a breast that has been radiated,” she says. “We also have excellent data demonstrating that implant reconstruction can have a much higher rate of complications in a radiated breast compared to a non-radiated breast.”

For all of these reasons, I knew reconstruction was not for me. My mastectomy was my first surgery. I wanted it to be my last. Cancer had taken a year from me, and I wanted to get on with my life. So, I took a different route. I opted for a form of chest wall reconstruction called aesthetic flat closure (AFC).

What is aesthetic flat closure?

Only officially added to the U.S. National Cancer Institute’s Dictionary of Cancer Terms in June 2020, AFC leaves a perfectly flat and smooth chest post-mastectomy. (This is in contrast to a standard mastectomy, where extra skin, fat and remaining breast tissue are usually left in place for future reconstruction.) An AFC can be done at the time of mastectomy, or in a separate surgery a few months later.

“Flat closure is a valid form of reconstruction in a patient who does not desire to have a breast mound made after her mastectomy,” explains Zhong, who notes that when an AFC is done well—meaning without redundant tissue or contour irregularity—most patients are highly satisfied with the procedure. (According to research published in Annals of Surgical Oncology in January 2021, of all mastectomy patients who chose AFC, approximately 75 percent are satisfied with their aesthetic outcome.)

That said, AFC is still a new concept for many surgeons and the available surgical literature is sparse. In the aforementioned research, approximately 20 percent of people surveyed indicated that their decision to go flat was not supported by their surgeon.

“The terminology around aesthetic flat closure has only recently entered into the mainstream conversation of breast cancer surgical care,” says Zhong. “I hope that more breast surgeons will offer it.”

AFC surgery typically has a four- to six-week recovery period, and it is often a more straightforward procedure than undergoing breast reconstruction. After my AFC surgery, which was done at the same time as my mastectomy, I recovered speedily and was back to my regular fitness and strength-building routine in less than four weeks.

I had never heard of AFC before until a Canadian friend of mine, a breast cancer survivor who was living in Boston, told me about it. When I raised the idea with my surgeon, I was fortunate he was on board with my decision and did a marvellous job. However, my choice baffled my friends and family, as well as my medical oncologist and radiation oncologist. I have learned that society and the medical profession are still inclined to equate femininity with the existence of breasts. I was a D-cup before my surgery. It seems that it was expected that I would want to restore my breasts and recapture what was taken away from me due to cancer.

Everyone is different, and no choice is wrong, but for me, there was no looking back. I was worried that reconstructed breasts would not feel natural. I knew they would not look the same. So, I chose to accept my new body and my new flat chest and celebrate the transformation that has been thrust upon me. In defiance of my circumstances, I embraced more daring fashion choices such as backless dresses, spaghetti straps and halter tops—all clothing options that were unavailable to me before I became a #flattie.

More Women are Choosing Aesthetic Flat Closure

In an editorial published in August 2023 in the Annals of Surgical Oncology, Dr. Jennifer Baker of the University of California speaks to a study published in the same issue that evaluated national rates of “going flat” after mastectomy. The study found that for the first time in nearly 25 years, there may be a reversal in the longstanding trend of increasing use of post-mastectomy breast reconstruction. In other words, more women are beginning to think twice about rebuilding their breasts.

In her practice, Zhong is observing a similar trend. “Now that we have a better understanding of how to perform aesthetic flat closure after mastectomy, supported by positive patient-reported outcomes following this type of closure, more women are choosing to undergo this type of procedure,” she says.

Talking to Your Doctor About the Flat Option

Flat is not for everyone, nor should it be—but people need to know it is an option. A knowledgeable woman facing the difficult recommendation of a mastectomy is better armed for a discussion about all reconstruction options with her surgeon and is better equipped to advocate for herself.

It’s been one year since I underwent my AFC. While I certainly wish my breast cancer had never happened, I have not a single regret about my decision to remain flat after my mastectomy.

This “flattie” is quite happy living with her choices.

Ellyn Winters is a breast cancer survivor, proud flattie, the author of the bestselling book Flat Please Hold the Shame, and the co-creator of AskEllyn, the world’s first conversational AI for individuals on a breast cancer journey. You can follow her on Instagram at @flatplease.