What It Means To ‘Go Flat’ After Mastectomy

With every mastectomy comes a big decision, and there are three surgical options regarding what happens next:

• A breast reconstructive surgery to add implants.
• Autologous reconstruction, also known as “flap” reconstruction. This surgery repurposes tissue from your abdomen, back or thighs to create a more natural-looking breast.
• A flat closure, also known as “going flat.” With this option, no volume is added, and the chest becomes flat.

You would choose flat closure if you’re certain you don’t want any volume in your breasts. Some women know immediately that this is what they want. Others might need to do more research before deciding.

What To Expect

Make a list of questions to ask your surgeon during your pre-op visit. If you can, task a friend or loved one with writing down the answers. It’s common for people to only recall about a third of the information shared during a doctor’s visit.

It may help to talk with other women who have faced this decision. You might find it helpful to connect with support groups online – such as dedicated flat closure Facebook groups – as well as hospital support groups. You might want your partner’s input, but ultimately, it’s your decision.

Your doctor may only recommend or allow the flat closure if you have comorbidities, including:

• Cardiovascular disease
• Uncontrolled diabetes
• Obesity; in this case, a BMI higher than 38

Any of the above reasons could deter your surgeon from approving you for any surgery other than flat closure. Later, if you’re able to get the comorbidity under control, you can return to the doctor and choose a different surgical option, such as implants. Insurance tends to cover this procedure, even if performed later.

After your surgery, don’t skip scar care. In the first few week's post-surgery, you’ll be asked to keep the scar clean and dry, wrap it in sterile bandages, apply ointment and manage the surgical drain, if used. In later weeks, the more that you moisturize the area, the better. Poor care can result in a wider scar or a hypertrophic scar, which is raised or thickened. Laser treatments can improve appearance, but the best course of action is to follow the care guidelines as best you can start right after surgery.

With any mastectomy, you’ll lose sensation in your breasts, which may last a few years or may be permanent. You may also feel a slight but persistent tingling – like ants crawling on your skin – due to nerve regeneration and nerve rewiring. In cold weather, your chest may feel clammy and painful. Gabapentin can help alleviate these sensations.

Nonsurgical Post-Mastectomy Options

Tattoos. Some women who choose flat closure also tattoo their chest. After six months have passed and provided the wounds heal properly, you have the option to tattoo over the surgical incisions.

External Prosthesis. After going flat, you might elect to wear a prosthesis for special events. These custom-fitted inserts are worn between your skin and a bra to give you fullness when you want it.

You won’t need an entirely new wardrobe, but you may find that your old shirts and dresses are now too big. You may have to size down in shirts and dresses. Women who choose to go flat tend to forgo regular bras moving forward, instead opting for sports bras or bralettes.

Delayed Care

If you choose to go flat and later discover that it’s not what you want, you can change your mind. Some women have found that they don’t feel like themselves anymore or that they can’t acclimate to the sight of their chest without volume. If this happens, you can choose to return to your surgeon and schedule a new procedure to add breast volume.

To make this surgery possible, the skin on your chest will be stretched more. One downside is that the breast expansion will be more painful than if implants or reconstruction occurred at the time of the mastectomy surgery.

Women who initially choose implants can also decide later to go flat. More commonly, older patients choose this to avoid further back and neck pain.

Cancer Recurrence

Most importantly, your risk of recurrence isn’t any bigger with any option. With a mastectomy, the surgeon removes the breast tissue and leaves the skin and subcutaneous layer.

Above all, your physical and emotional health come first. If you have any questions about the surgery or any part of your healing journey, you’re encouraged to ask your surgeon or anyone else who is part of your hospital care team.