Going flat

Going flat means choosing not to have breast reconstruction after mastectomy—whether you have one or both breasts removed.

Some women decide they want to go flat after talking with their surgeons about breast reconstruction options.

Since 2016, the Going Flat movement, led by patient advocates, has called more attention to going flat as a valid choice after mastectomy. In 2021, a survey of 930 women found that nearly 75% were satisfied with their choice to go flat. Close to 25% also said they didn’t feel supported by their doctors in making that choice.

A woman can choose to go flat immediately after mastectomy or later, after having breast reconstruction. There are many reasons why a woman may choose to go flat. Sometimes, problems with breast reconstructions can lead to a decision to go flat rather than undergo more surgery to correct a reconstruction issue.

Below, you can learn more about going flat—one of many options as you make decisions about breast reconstruction.

Reasons why people decide to go flat

Some people choose to go flat because they don’t want to go through the breast reconstruction process. For others, reconstruction isn't a good option because of other health conditions, out-of-pocket costs, or life circumstances (such as work or caregiving demands).

Some common reasons for deciding not to have breast reconstruction include:

• Faster recovery time: It can take a few weeks to recover from mastectomy alone. With reconstruction, it can take anywhere from 4-8 weeks.
• Wanting to avoid more surgeries: If reconstruction can’t be done at the same time as mastectomy (immediate reconstruction), some people would rather not have another surgery later. Even after reconstruction, more procedures are often needed to produce a good result. Many women decide they don’t want any more surgery.
• Preferring not to have implants: Implant reconstruction is more widely available than tissue reconstruction and has a shorter recovery time. But implants have silicone ingredients, and some women would rather not have artificial materials inside their bodies. Tissue expansion can be another part of implant reconstruction. This process is often needed to stretch the skin to create space for the implant. It can take 6-8 weeks and can be painful for some women.
• Not wanting to go through tissue reconstruction: Tissue reconstruction requires having surgery on another part of the body, such as the belly, thigh, or buttocks. The surgeon removes tissue (called a “flap”) that will be used to create the new breast. This requires more recovery time, and more scarring compared with flat closure.
• Feeling OK about not having breasts: Some women are fine with not having the appearance of breasts, knowing that reconstructed breasts won’t look or feel exactly like what they had before. Others choose to wear a prosthesis (breast form) if there are times when they want the look of having breasts.
• A desire to get back to normal activities more quickly: Women may be caring for children or relatives, working at a job that is physically demanding, or living an active lifestyle they enjoy. They might not want to invest time in the reconstruction process and recovery.

In some cases, reconstruction may not be recommended due to the extent of the cancer.

In other cases, people go flat because they face practical challenges to having reconstruction. Here are some examples:

• Certain health conditions: Conditions such as diabetes, obesity, or heart or lung problems can increase the risk of complications with breast reconstruction.
• Lack of access to plastic surgeons who perform tissue reconstruction: While implant reconstruction is widely available, tissue flap reconstruction is not, because it requires training in microsurgery (joining tiny blood vessels together). If someone doesn't want implants but can’t travel for tissue flap reconstruction, she may decide to go flat.
• Not enough tissue for flap reconstruction: Women with a thin build might not have enough extra tissue in the belly, thighs, or buttocks to create new breasts. They may prefer to go flat rather than use implants.
• Out-of-pocket costs: Health insurance plans are required to pay for breast reconstruction. Plans vary, though, and some people might not be able to afford the out-of-pocket costs of breast reconstruction. Or they might simply decide the cost isn’t worth it.

Every person’s situation is different. You and your care team can discuss the pros and cons of going flat versus having breast reconstruction.

Communicating with your surgical team

While there are many breast surgeons who perform flat closure, plastic surgeons generally have more experience with this surgery.

Some surgeons strongly encourage breast reconstruction after mastectomy. They might not mention going flat as an option. They also might dismiss the idea if you bring it up.

Some women who asked to go flat after mastectomy have reported that their surgeons left extra skin behind, just in case they eventually wanted reconstruction. Or, their surgeons simply did not have the experience and training to achieve a smooth, flat result. Advocates call this flat denial.

It’s important that you feel heard when you’re letting your breast surgeon know your wishes. You might want to:

• Search online for “flat closure results” and bring images that show the results you want.
• Ask the surgeon how often they perform aesthetic flat closure, and if they have completed training in how to do the procedure.
• Ask to see photos of their flat closure work.
• Ask if you can speak with any of their former patients who had flat closure.
• Request that your breast surgeon partner with a plastic surgeon experienced in flat closure.

If you are feeling pressured to have reconstruction even after letting your surgeon know you want to go flat, seek a second opinion with another breast surgeon or a plastic surgeon. It’s important to be able to go into surgery feeling confident that your surgeon knows what you want.

If you’re having flat closure after a past reconstruction, whether with implants or tissue flaps, you’ll already be working with a plastic surgeon. You can ask how much experience they have with aesthetic flat closure.

Not Putting on a Shirt offers support and guidance on how to advocate for yourself if you have decided to go flat.

Living flat

Mastectomy is a major change to the body that can impact how you feel about yourself.

Whether someone chooses breast reconstruction or decides to go flat, the chest area will feel and look different than it did with natural breasts. That can be a big adjustment, so give yourself time to get used to your post-surgery body.

Living flat—whether you’re fully flat or flat on one side—can be different for everyone:

• Some people feel comfortable going flat all the time.
• Others decide to use a breast prosthesis, an artificial breast form that can be worn inside a bra or on the chest to create the appearance of breasts. There are many different types available, ranging from lightweight pads to silicone breast forms. A breast prosthesis is something you can wear whenever you want—whether it’s all the time or just once in a while.

Dressing flat

Dressing with a flat chest may feel different at first. Some people find it helpful to choose tops that camouflage the chest, including:

• Draped or ruffled tops
• Dark colors and patterned fabrics
• T-shirts layered with a jacket, sweater, scarf, or shawl
• Athletic tops or swim tops with some built-in padding

The websites of advocacy groups such as Not Putting on a Shirt and Flat Closure Now feature some great ideas for dressing with a flat chest. You can also find ideas by searching on social media. You’ll notice that some women even choose decorative tattoos to make a statement with their flat chests.

Sex and intimacy after going flat

Sexuality and intimacy can feel different after going flat, especially if your natural breasts were a source of pleasure. After mastectomy, there will be less sensation in the chest than before.

The same is true for women who choose reconstruction with breast implants or tissue flaps. That’s because removing breast tissue also cuts the nerves that provide feeling to the chest. Whether you have a romantic partner now or plan to date in the future, open and honest communication will help you figure out what works for you.

As author Catherine Guthrie wrote, “Post-cancer sex will never be the same as pre-cancer sex because YOU are not the same. My partner and I struggled to regain intimacy after my double mastectomy. But it wasn’t because I’d lost my breasts; it was because I’d lost my confidence. Once she made it clear that body confidence was much sexier to her than breasts, I realized I’d been fixated on what I lost instead of what I had—a beautiful, vibrant, healthy body!”

Whatever your concerns are after going flat, give yourself time to experiment and figure out what works for you.