Patients Who Choose to 'Go Flat' After Mastectomies Report High Satisfaction

By Carolyn Crist

February 05, 2021

NEW YORK (Reuters Health) - Most women who received a mastectomy and decided to "go flat" rather than undergo breast reconstruction reported that they were happy with their surgeries, according to a team of surgeons and oncologists.

As part of a growing "Going Flat" movement, more women may decide to avoid breast reconstruction, and surgeons should recognize and discuss patients' decisions around mastectomies, the team writes in the Annals of Surgical Oncology.

"Much of the surgical literature notes that women who do not undergo immediate reconstruction are less satisfied compared with those who opt for immediate reconstruction. There seemed to be a bit of a disconnect between what I was reading, compared with what I was hearing from my own patients," said senior author Dr. Deanna Attai of the University of California at Los Angeles and Burbank Breast Care Center.

In recent years, advocacy groups and online communities have promoted the "Going Flat" movement to increase awareness and acceptance that mastectomy alone is a viable option.

"If the surgical literature notes that patients who go flat are not happy, then surgeons are less likely to encourage (or even discourage) that option," she told Reuters Health by email. "We felt that it was important to document the experience of this group of women."

Dr. Attai and colleagues surveyed 931 patients who had a mastectomy to treat breast cancer or elevated breast-cancer risk without breast-mound reconstruction. They asked questions about overall satisfaction with the surgery, as well as specific questions about appearance and confidence. The research team also asked about preoperative counseling, including whether surgeons supported patients' decisions to go flat.

Overall, 74% were satisfied with their surgical results. However, 22% reported an experience of "flat denial," or a lack of preoperative counseling or support, which was the strongest predictor of dissatisfaction with the surgery.

The highest satisfaction scores were associated with having adequate information to make an informed decision and having a surgeon who specialized in breast surgery.

At the end of the survey, patients could comment in an open response section. One patient wrote, "I was never given the choice of going flat; it was like I was 'expected' to have reconstruction."

Another wrote, "I stated multiple times that I intended to stay flat . . . after surgery they told me they left extra skin in case I changed my mind."

About 27% of patients said they weren't satisfied with the appearance of their chest wall. Aesthetically-pleasing flat closure typically requires specific surgical techniques to prevent excess skin, the authors write. Surgeons should be familiar with a variety of techniques and consider collaborating with plastic and reconstructive surgeons because different solutions may suit specific body types better, they add.

"This is important because we are now understanding that the surgery may take more than 'just' removal of the breast," said co-author Dr. Don Dizon of Brown University in Providence, Rhode Island. Dr. Dizon is the director of women's cancers at the Lifespan Cancer Institute.

"There is an art to reconstructing a flat chest," he told Reuters Health by email. "Attention to symmetry, removal of any extra skin and minimization of postoperative scars are all important."

A limitation of the study is that it relied on self-reported information, and the majority of participants were active in online Going Flat communities. The survey participants were also predominantly white, young and had high education and socioeconomic levels.

Future studies should include older women, those without private insurance and women in racial or ethnic minority groups, the authors say.

"It is important to ask the same questions to women who chose to go flat after mastectomy as the women who chose reconstruction after mastectomy and understand the different decision-making factors that ultimately contribute to long-term patient satisfaction," said Dr. Toni Zhong of the University Health Network Breast Reconstruction Program in Toronto, Canada. Dr. Zhong, who wasn't involved in the survey, researches patient outcomes after breast reconstruction.

"High-quality surgical decision-making is an important determinant of long-term patient satisfaction," she told Reuters Health by email. "Patients consistently report great satisfaction with their decisions when they feel supported."

SOURCE: Annals of Surgical Oncology, online January 3, 2021.