Breast Reconstruction Is a Personal and Complex Choice

Beth Fairchild says she just wanted her breasts gone.

After a two-year search to find a surgeon willing to perform her mastectomy, she worried that complications from any possible breast reconstruction could interrupt lifelong cancer treatment. So, she opted to go flat.

“I didn’t want to have any complications that could then mean I was going to have to extend my treatment, which means my cancer would grow, and then I could die,” said Fairchild, 39, who was diagnosed with stage IV de novo breast cancer in 2014. De novo means breast cancer is metastatic at first diagnosis. Doctors told her that a mastectomy would not prolong her life, because the cancer already had spread.

“I told the surgeon, ‘I want to look like a 12-year-old boy,’” said Fairchild, who lives in Greensboro, North Carolina, and works as a tattoo artist. “I had the mastectomy, and I loved it. It was like having a mole or cyst removed. The results were amazing.”

But three years later, with her health stable due to continuing treatment, she started to rethink her decision. She was tired of paying to alter her clothes, buying tops off the kids’ rack and having nothing to fill a bikini top. She had breast reconstruction with implants last year.

“I felt like I was in a good place physically and mentally to reconstruct,” she said. “I have always loved to be on the beach and be in a bikini. I said, ‘I just want to be a normal person, normal for me. I want to be able to buy a shirt off the rack and put it on and wear it like everyone else.’

“I’m still not quite used to my body unclothed,” she added. “It looks weird to me, because I got so used to seeing my flat self. But in clothes and in a bathing suit, I feel so much more like myself and so much more confident.”

Psychological Benefits of Breast Reconstruction

For years, doctors have automatically assumed a woman would want reconstruction. Women’s health advocates lobbied for the Women’s Health and Cancer Rights Act of 1998, a federal law that required health plans to cover prosthetics and reconstructive procedures.¹ Since then, breast reconstruction has become standard care for breast cancer treatment.

In fact, there were 101,657 breast reconstruction procedures in 2018, according to the American Society of Plastic Surgeons. The organization reports a 29 percent increase from 2000 to 2018.²

The quality of life and psychosocial benefits of reconstruction are well-documented. One study found women who underwent breast reconstruction after a mastectomy using their own abdominal tissue felt better about themselves as soon as three weeks later.³ The women reported improvements in satisfaction, psychosocial well-being and sexual well-being.

“The breast is so socially and culturally and personally important to women,” said Dr. Deanna J. Attai, a breast surgeon at UCLA and a past president of the American Society of Breast Surgeons. “To not only have a diagnosis of cancer but to lose such an important part of your person and your identity, for many women, it’s a hard psychological adjustment to make after surgery.⁴

“To be able to put on your normal clothes, put on a bathing suit, kind of go about your life … ‘at least to the outsider or to my family, I look kind of normal’ and to the woman that can be what she feels is normal. That can be an important part of the psychological recovery.”

The “Going Flat” Movement

Still, an increasing number of women are opting to go flat—about 25 percent. Attai and a colleague recently surveyed the “going flat” population online to assess their satisfaction. The abstract is embargoed until later this month.

“There’s a growing percentage of patients who just say, ‘Why do I need to do anything?’” she said. "'Why can’t I just have my breasts removed because they need to be due to the cancer or an inherited mutation?' What I hear from women is ‘I’m not defined by my breasts.'"

Many women who opt to go flat are turned off by the thought of more surgery. In the case of implants, some are worried about having something foreign placed in their body. There is an increasing awareness of breast implant illness, including a rare type of cancer called anaplastic large cell lymphoma.

Even if a woman opts for flap surgery (using tissue from another part of the body to shape the breasts), the procedure often requires more surgery and a longer recovery. Not to mention a woman may not have enough fat to undergo the procedure.

Also, since most women lose sensation in their chest after a mastectomy, it becomes a question of whether reconstruction is really worth it.⁵ A handful of U.S. surgeons are using microsurgical neurorrhaphy to reconnect nerves and restore feeling to reconstructed breasts.

“They are complicated discussions and complicated decisions, made even more complicated by the fact that they are often happening at a time of diagnosis with cancer,” Attai said. “I think many patients feel the pressure to make a decision quickly, because they feel like they need to move on with things to make sure they get the cancer taken care of when most of the time patients really have the time to look at all the different options.”

Fairchild said many women were critical of her decision to have reconstructive surgery.

“There are a few people who are really more gender-neutral and their flat bodies fit the person who they are on the inside, and they are very comfortable with that, and I think that’s great,” she said. “But I am very much a feminine woman. I am feminine and love having curves."

“I’m still very much an advocate,” she added. “If you want to be flat, be flat. I am an advocate for a woman’s choice. You have a right to choose what you want.”