Reconstruction, Prosthesis, or Flat After Mastectomy?

There is no right answer as to whether or not to reconstruct a breast after a mastectomy. What matters most is that women are presented with all available options and that those options be clearly explained—specifying benefits and limitations of each possibility. Unfortunately, that’s not always the case.

Studies have shown that most women don’t feel fully informed about their reconstruction options. Discussing the benefits of not reconstructing a breast may motivate some women to forgo it. And when they do, according to recent UCLA research, 74% of women are satisfied with their decision to “go flat.” The researchers say that adequate information and physician support played a crucial role in helping women feel satisfied with their decision.

“Undergoing a mastectomy with or without reconstruction is a very personal choice,” says Deanna Attai, MD, an assistant clinical professor of surgery at the David Geffen School of Medicine at UCLA and senior author of the study published in the Jan. 3, 2021, issue of Annals of Surgical Oncology. “We found that for a subset of women, ‘going flat’ is a desired and intentional option, which should be supported by the treatment team and should not imply that women who forgo reconstruction are not concerned with their postoperative appearance.”

Key Study Findings

The results challenge past studies showing that patients who chose not to undergo breast reconstruction tend to have a poorer quality of life, compared with those who do have the surgery.

The study authors believe the survey tool commonly used to assess outcomes was biased towards reconstruction. To avoid that bias, the researchers partnered with patient advocates to develop a unique survey to assess reasons for going flat, satisfaction with the decision, and factors associated with satisfaction. The average age of the survey respondents was 49 (range, 25 to 85 years). Study participants were pulled from a pool of women who were active in the Going Flat community, and they all underwent mastectomy without reconstruction. Reasons chosen for going flat included faster recovery, fewer complications, and the avoidance of a foreign body.

Mastectomy Indications

Treatment for breast cancer can include mastectomy, but in some cases, breast-conservation surgery may be an option. This procedure is also known as lumpectomy or partial mastectomy and involves removing the tumor while sparing most of the breast. The American Cancer Society stresses that having a mastectomy instead of breast-conserving surgery plus radiation only lowers your risk of developing a second breast cancer in the same breast. It does not lower the chance of the cancer coming back in other parts of the body, including the opposite breast.

Hollywood Influence

Several years ago, a number of Hollywood celebrities began sharing their decision to have a double-mastectomy to reduce the risk of future breast cancer. In 2013, actress Angelina Jolie had both breasts removed because she carried mutations in the BRCA1 gene (BReast CAncer gene1), which dramatically increased her risk of developing breast and ovarian cancer. Normally, the BRCA1 and the related BRCA2 (BReast CAncer gene 2) genes suppress tumor development. But women who carry mutations in those genes aren’t protected by the tumor suppression factor and so are much more likely to develop breast cancer.

According to the National Cancer Institute about 13% of women in the general population will develop breast cancer sometime during their lives. By contrast, about 60% of women with mutations in BRCA1 or BRCA2 genes will develop breast cancer by 70 to 80 years of age. Jolie’s story inspired many women at high risk for breast cancer to undergo genetic screening. However, all the media attention likely led to unnecessary double-mastectomies, too.

A 2017 study published in JAMA found that nearly half of women diagnosed with early-stage breast cancer who did not have bilateral disease, genetic mutations, or elevated genetic risk considered having a double mastectomy anyway. About 19% of women who reported not receiving a recommendation for or against the prophylactic procedure from a surgeon had both breasts removed. There is no compelling evidence that doing so provides any survival advantage to women who are not at high risk. In fact, the researchers point out that the risk of contralateral breast cancer development is low for most patients.

Choices Post-Mastectomy

In the United States, reconstruction is available to most women after mastectomy. Reconstruction with implants typically involves inserting implants filled with either silicone gel or saline (sterile salt water). The U. S. Food and Drug Administration recommends that women with silicone breast implants undergo screening for potential rupture three years after implantation and then every three years thereafter. No long-term screening is suggested for saline implants.

Tissue reconstruction of the breast is a procedure in which surgeons remove and use skin from another part of the body, usually the abdomen, back, thigh or buttocks. The procedure takes more time, and the downside is there are scars on two areas of the body. The approach may lead to more natural looking breasts, but some women may need brief correction ­surgeries to achieve the best results.

A prosthesis is another available option. There are many breast shapes, sizes and materials from which to choose. The prothesis may be an insert that can be slipped into a pocket in a specially-designed camisole or bra. There are also those that come with adhesive patches or magnets that enable the prosthesis to stay in place without the need for special lingerie.

Going flat is another choice. However, the American Society of Plastic Surgeons states that more than 70% of women are not fully informed about this option.

Flat Denial

Forgoing breast reconstruction can be a viable choice for many women, but there may be some obstacles. The recent UCLA study identified concerns unique to patients who chose not to have breast reconstruction. While a majority of the women surveyed who decided against reconstruction reported they were satisfied with their surgical outcomes, 27% reported not being satisfied with the appearance of their chest wall.

“Some patients were told that excess skin was intentionally left, despite a preoperative agreement to perform a flat chest wall closure, for use in future reconstruction, in case the patient changed her mind,” says Dr. Attai, “We were surprised that some women had to struggle to receive the procedure that they desired.”

Surgeons may hesitate to recommend mastectomy without reconstruction surgery due to being less confident that they can provide a cosmetically acceptable result for patients who desire a flat chest wall, notes Dr. Attai. “We hope the results of the study help to inform patients that going flat is an option, and to empower them to seek out surgeons who offer this option and respect their decision.”

Carefully Consider Options

A breast cancer diagnosis may, understandably, cause a person to panic. But there is time to carefully consider options and treatment plans, according to Jennifer Baker, MD, Assistant Clinical Professor of Surgery at the David Geffen School of Medicine at UCLA, and a researcher on the recent study. She advises newly diagnosed people to seek out breast cancer surgeons who have done surgery fellowships, so that they are familiar with the most recent techniques.

To more fully understand treatment options for breast cancer, view Dr. Baker’s excellent YouTube video online by entering the following information into the internet search bar: http://tiny.cc/breastcancersurgery.  

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