After a mastectomy, some women do not want their breasts replaced

Many of those who requested the procedure say they faced resistance – and outright rejection – from their doctors when they offered it.

(Jimina Estepalez for The Washington Post)

While training as a breast surgeon, Diana Attay, assistant professor at UCLA’s David Geffen School of Medicine, read studies and heard from counselors that women who chose not to have breast reconstruction after mastectomy had a lower quality of life overall.

But Attay found it contrasted with what she’s seen online in recent years: Facebook groups with names like “Don’t Wear Shirt” and “Flat and Fabulous” that included many happy stories about women — and pictures — as they chose. Closure” is the term the National Cancer Institute uses as of 2020 to forgo breast reconstruction.

So Attay conducted her own survey of nearly 1,000 women who had had a single or double mastectomy without reconstruction. It was published last year in Annals of Surgical Oncology and found that nearly three-quarters of women said they were satisfied with the result.

No government or organization keeps track of the final closing number each year. According to the National Breast Cancer Foundation, about 277,000 cases of invasive breast cancer occurred in 2020 in the United States. The American Society of Plastic Surgeons reports that about 140,000 mastectomy operations were performed that year, about half of which involved additional reconstructive surgery.

Flat closures have always been an option, but Anne Marie Champagne, a doctoral student at Yale University researching the issue, says there has been a shift in attitude toward flat closures in online conversations since 2012. Champagne, 53, who chose flat closures after 2009 mastectomy, says before 2012 there were only two posts about flat closures on the Breastcancer.org message board. “That year, I saw a message from the founder of the advocacy group Apartment Close Now! Who says: I want to see you. I want to form a union. I want to be flat… If that’s your choice, I hope the women who see me see me, as flat as they can be.” , and that rebuilding does not equal the path.

What shocked Champaign was not only the content of the letter, but the number of people who read it. “The Breastancer.org posts have garnered more than 2,000 views,” Champagne said. ” [That] The post garnered 79,000 views and 3,500 comments within six months of being published.

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While many women still choose breast reconstruction, figures from the American Society of Plastic Surgeons show, Champagne and others who have been involved in the cause of flat closure ticked off their list of reasons, including increased awareness of the option, for what doctors and cancer surgeons say. There is a growing interest in downtime.

« J’ai certainement vu plus de patientes demander à se mettre à plat après une mastectomie, probablement parce qu’elles se sentent plus habilitées à prendre cette décision », déclare Roshni Rao, MD, chef de la chirurgie mammaire au University Medical University Columbia in New York.

« Diagnosticer le cancer du sein peut être particulièrement difficile car il ya tellement de décisions à prendre en peu de temps, y compris les choix des médecins, le plan de traitement et la poitrine d’une femme aprèstomie une mail » electronic. There is a greater awareness now that the process of reconstruction carries risks. “Women who choose to have reconstruction, whether using breast implants or their own tissue (called autologous reconstruction), can face multiple surgeries, recover after surgery, a 10% risk of infection that may disrupt their chemotherapy or radiotherapy regimen, and sometimes removal implants and deletion.

For women who want reconstruction, Atay says, they often believe the effort and risk is worth it. “But for others, it is not so.”

It wasn’t about Pepper Segal from North Carolina, who was diagnosed with breast cancer three years earlier during pregnancy at age 31. She delivered at 36 weeks and started chemotherapy two weeks later. But soon after, she felt pain in her armpit which led to the spread of the cancer. Segal underwent an emergency mastectomy and decided to remove both breasts and lay them flat.

“I was told that if I wanted to rebuild, I would have to wait two years because the type of cancer I have had a high recurrence rate and it could be difficult to detect with implants or autologous reconstruction,” she says. But I decided to close the apartment. I didn’t want to put my body in anything else. »

Seagal says she “thanks God for Billie Eilish” and for her signature loose-fitting outfit. “I can wear loose-fitting clothes, and it looks great now.”

Sagit Meshulam-Derazon, a plastic surgeon at Rabin Medical Center in Tel Aviv who specializes in breast reconstruction, said she and her medical partner, who is also a plastic surgeon, recently talked about the choice they would make if they were diagnosed with breast cancer. cancer. . They both agreed that they would opt for the flat closure, noting that expectations about what a woman should look like has changed a lot.

“Look at actress Andy McDowell, who is now playing roles without coloring her hair gray,” says Mishulam Derazon. “What a woman looks like these days is often what she chooses to appear, not the perfect image.”

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Champagne also says she believes that online photos of transgender men’s chests purged after a mastectomy played a role.

“I had many friends who had converted in the years before my diagnosis and surgery, and seeing what their flat chests looked like made me feel like I had more options,” she says. “Socially, we are becoming more open to a wider range of bodily expressions.”

However, women in the Attai survey, as well as posts on social media pages of Flatlock advocacy groups, have found that some women encounter resistance and outright rejection from their doctors when they bring up the idea of ​​shutting down or say that’s what they want.

About 22% of the women who responded to my inquiry said the flat closure option was not initially offered by the surgeon, was not supported by the surgeon, or the surgeon intentionally left extra skin in case the patient changed her mind. This extra skin will require further removal surgery if the woman does not change her mind about the flat closure.

“I’ve done you a favor,” Champagne’s doctor told him when he walked into his hospital room after a mastectomy to explain that he had extra skin left for resurfacing.

“Even though I had surgery I think we were fine with the lockdown,” Champagne says. “I made my wishes clear. He replied that through his experience, all breast cancer survivors rebuild their bodies in six months. When I heard his words I felt deep sadness and a mixture of sadness and anger. I couldn’t believe the surgeon was making a decision for me when I was anesthetized it was against everything.” We discussed it – which I accepted.”

She is not currently considering revision surgery to remove the excess skin.

Kim Bowles, 41, of Pittsburgh, says her surgeon’s decision to ignore her stated decision to close the apartment prompted her to start the advocacy group No Shirt Wear. “When the sedation started, I heard the surgeon say he’s going to leave some skin, in case I change my mind, and it was too late to protest. I woke up with a look I didn’t want,” she said.

Now, the organization’s website includes a list of plastic surgeons who perform cosmetic flat closures and provides talking points for patients to help them discuss the procedure with their doctors. Bowles underwent a revision process three years after the initial surgery.

Not an option for everyone

Not everyone can have or want a flat closure. Kelsey Larson, MD, chief of breast surgery at the University of Kansas Health System, says it’s important for patients to first consider how any surgical options might affect cancer treatment and breast cancer outcomes.

“It is very important for patients to remember that they are having a mastectomy for medical purposes, as part of preventing or treating cancer,” she says. Larson says she would “encourage any patient receiving cancer care to ask questions” specifically about these issues.

Years ago when my twin daughter had breast cancer, I took drastic measures and I’m thankful I did.

Elisabeth Mittendorf, MD, chief of surgical oncology at Harvard’s Brigham and Women’s Hospital in Boston and a Susan G. Komen Foundation researcher, says heavyweight patients especially need to talk to a plastic surgeon, rather than a general surgeon, before choosing an apartment closure procedure. And be prepared that the look may not be the sleek, flat look you want.

Excess tissue in women who carry more weight often means it’s not possible to achieve a smooth, flat appearance, Mittendorf says. More than one surgery may be needed to allow parts of a woman’s body to heal before the procedure can be completed.

Larson says that while she welcomes the growing interest in flat closures so women can choose which option they want, she is concerned that women who want to have breast reconstruction after mastectomy are now feeling hesitant.

“I’ve had patients in recent years whisper to me that I want to be reconstructed,” she says, fearing they might be misjudged for choosing the breasts. »

Evidence of the growing interest in flat closures have emerged sessions on how to communicate with patients at breast cancer medical meetings. Atay and defenders like Bowles were invited to give presentations.

That’s important, says Scott Kurtzman, MD, chief of surgery at Waterbury Hospital in Connecticut and chair of the National Breast Center (NAPBC) accreditation program, a program of the American College of Surgeons.

“I’m sure there are a lot of surgeons out there who have their own idea of ​​what female aesthetics should be and have a hard time articulating that and accommodating people who don’t share the same opinion,” Kurtzman says.

NAPBC now requires breast centers to report to the board of directors on how they participate in decision-making regarding post-mastectomy options and demonstrate that they accept patient requests for the esthetics of their choice.

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