Reconstruction Post-Breast Cancer Surgery Is Not a Given, Anymore

In 2016, Kim Bowles, then 35 and a mother of two, faced the loss of both breasts due to cancer. Bowles went to the office and told her doctor she didn’t want breast reconstruction, she wanted her breast flat.

Her decision, which was clearly communicated to her surgeon, was not followed. “I brought photos, I brought a witness, I did everything I could to protect my choice,” said Ms. Bowles, who lives in Pennsylvania. Instead, the surgeon left two flaps of skin in case she changed her mind. Ms. Bowles experienced “flat rejection,” the reaction of a surgeon who, for some reason, did not grant a patient’s request.

Despite the surgeon, Ms. Bowles went flat and started an organization called Not Putting On a Shirt (NPOAS) whose primary purpose is to teach women how to tell their doctor that they want to be flat, not reconstructed, and endorsed a woman’s right to have all information about all the options available to her.

Research on patient outcomes in the past found that women who had a reconstruction were “happier” with either silicone breast implants or reconstructions. Authors of a 2013 survey said women who had successful reconstructive surgery were “significantly more satisfied” with their decision than those who had reconstruction opted for the mastectomy alone.

But what kind of team from the University of California, Irvine, studied seems to be unique.

A new attitude

Deanna Attai, MD interviewed 931 women who walked flat. Dr. Attai found that 74% were satisfied with their decision. But 22% of these women have been turned down by their surgeon for their choice, who in some cases, like Ms. Bowles’ surgeon, left the skin behind for future reconstruction just in case. “We were surprised that some women were having difficulty getting the procedure we wanted,” said Dr. Attai in a press release. Her work was published in the journal Annals of Surgical Oncology.

Flat rejection is more than disregarding the patient’s wishes; it can change the outcome of the operation. Dr. Attai noted that “a high level of shallow rejection” was the “strongest predictor of dissatisfaction with the surgical outcome,” meaning that women who felt unsupported felt less good about their post-operative bodies to surgeons who specialize in breast surgery and said they were more satisfied with their results.

Well-established ideas and beauty standards also lead to blanket rejection, according to Ms. Bowles. “Women are supposed to have breasts, and that’s part of a woman’s worth,” she said. But to appreciate for a woman that she is still a whole woman, breasts or not, “is kind of radical”.

Dr. Attai also addressed this: “We have found that for a subgroup of women the ‘flat’ is a desirable and deliberate option,” she said in a press release, “… and should not imply that women are on the Refrain from reconstruction, this does not concern their post-operative appearance. “

Kim Bowles, topless, founder of NPOAS. Photo of Charise Isis from the Grace Project, in short, no shirt on.

The impact

As Dr. Attai has proven that “shallow denial” not only makes patients less satisfied with their results, but can also affect other areas of life. “It’s a serious trauma that happens to women,” explained Bowles. “These are women who are usually either at high risk of breast cancer or who are already on breast cancer treatment. They look to a future filled with medical treatments.” There is a levy on people like Bowles and others whose wishes are ignored: “When a health care provider violates your trust in such a tremendous way, it definitely affects you,” she said.

Raids and Progress

Surgical flattening requires skill, and doctors more familiar with performing reconstructions may be less confident with a mastectomy performed alone.

Another problem is that fluttering is not an officially designated medical procedure. Ms. Bowles said there is no specific medical billing code and this can be a problem for surgeons who are paid. “Surgeons who do extra work and spend extra time in the operating room to get a good aesthetic result should be compensated,” she said.

But at least there is an official definition for flat. In June 2020, as a result of lobbying by NPOAS, the National Cancer Institute added a flat definition to its dictionary so that patients could explain what they wanted. The new term: aesthetic flat lock. An NCI spokesperson said a team of two scientists, two oncology nurses, and others viewed the term as a relevant addition to the institute’s dictionary.

Infographics (1) The official medical definition of “going flat” Dictionary of Cancer Terms from the National Cancer Institute

A bill is currently being proposed in Vermont to revise coding and accounting standards. Medical Daily’s request for a statement from the bill sponsor, Representative Charen Fegard, was not returned in due time.

Reasons for saying “no reconstruction”

Breast cancer is the second most common cancer in women, according to the CDC. The women in Dr. Attai’s polls were white, married, and privately insured on average in their late forties. Dr. Attai admitted that her survey data came from people who were active in online communities and ran flat communities, which could lead to a bias in the data.

Dr. Attai also evaluated why women chose to walk flat in their study. She found that some women who did this cited the shorter recovery time, while others believed that reconstruction was unnecessary for their body image, and others wanted to forego breast implants for good reason.

In 2019, the FDA asked Allergan, a manufacturer of breast implants, to recall some of their implants. The recall came in response to research linking structured implants to implant-associated anaplastic large cell lymphoma, a form of cancer. “The FDA has been carefully monitoring this issue since we first identified the possible link between breast implants and ALCL in 2011,” said Amy Abernethy, MD, PhD at the time. “Based on new data, our team concluded that this action is currently needed to protect public health.”

Some women worried about an implant have chosen not to have a reconstruction, Ms. Bowles said. “I think there is a growing awareness of the complications of implant reconstruction, which is related to the increased awareness of the aesthetic flat closure as a legitimate and safe option,” she said.

Dr. Attai also addressed this: “We have found that for a subgroup of women the ‘flat’ is a desirable and deliberate option,” she said in a press release, “… and should not imply that women are on the Refrain from reconstruction, this does not concern their post-operative appearance. “