If you’re a breast cancer survivor who has implants or tissue expanders and are considering having them removed, you may have found yourself musing, “What if I got rid of them, and replaced them with… nothing?” If that sounds familiar, you’re not alone. What you’re contemplating is called “Aesthetic Flat Closure” (AFC) and it’s the subject of my book, Flat and Happy.
Flat closure isn’t a new thing. Doctors have been performing flat closures (with varying degrees of competence) for as long as there has been mastectomy surgery. But in 2020 advocates in the flat community got the term “Aesthetic Flat Closure” added to the National Cancer Institute’s dictionary of cancer terms, whereupon the clouds parted and a heavenly choir sang out.
OK, not really. But it was an incredibly important development for the flat (and flat curious) community, because it provided a way to describe a procedure in which the cosmetic aspects of the surgery are handled with as much care and artistry as they are in breast mound reconstruction. In fact, AFC is defined as a reconstructive process, since it involves rebuilding and contouring the chest wall to provide a clean, smooth, and pleasing appearance.
The adoption of this term, as opposed to just regular old “flat closure,” signals a growing recognition that choosing not to have breast mound reconstruction doesn’t mean you don’t care about your appearance. What it likely does mean is that you value the appearance of “normalcy” less than certain other health and lifestyle factors. Many patients go flat because they are uncomfortable with the idea of foreign objects in their bodies. For others, the primary motivation is the desire to avoid additional surgery or to lower the risk of post-surgical complications.
But if you underwent implant-based reconstruction after mastectomy, a different set of reasons was guiding your thinking. Your own sense of self may have persuaded you that you would feel more whole if you had breast mounds. Or a medical professional or a loved one may have convinced you that you wouldn’t be happy without breasts. Whatever the reasons, you’ve likely invested a lot of time, effort and pain into the process of getting those implants. It’s not easy to flip the script for yourself now and contemplate life without them.
I never had to face explant because I went straight to flat. But over the course of writing Flat and Happy, I spoke with a number of patients who had explanted to flat. Here are a few of the things they discovered in the process:
You are not your breasts (or your implants)
Society does its best to convince women that their worth is somehow connected to the mounds of flesh on their chests. But the people who love you (and I mean truly love you) are much more interested in the content of your mind than the shape of your chest. They are more attracted to the warmth of your smile and the sparkle in your eyes than they are to whatever’s in your bra. If you’re struggling to see beyond your socially inherited breast-related self-concept, Busting Free, the award-winning self-help book for women who explant or explant to flat, is a game-changing resource.
Not all flat closures are created equal (and not all surgeons have the skill to deliver an aesthetic flat closure)
A successful AFC creates a smooth, flat chest wall without bags of excess skin, prominent areas of concavity or other cosmetic defects. And as more and more patients are becoming aware of AFC as an option, more and more surgeons are educating themselves in the techniques for AFC. Unfortunately, though, there are still plenty of surgeons out there who have never heard of AFC, and who choose to believe that aesthetics don’t matter to a patient who goes flat.
I have seen some truly horrifying surgical outcomes, some of which were perpetrated by plastic surgeons. In other words, it’s not enough to assume that someone should have the expertise to deliver a cosmetically satisfactory surgical result. You have to interview your surgeon (whether they are a breast surgeon or a plastic surgeon specializing in explantation surgery) to ensure that they understand your expectations and are skilled in the necessary techniques to ensure that you will be happy with the outcome.
If you are in any doubt as to whether your surgeon is capable of performing a proper aesthetic flat closure, consult the registry of flat-friendly surgeons available on notputtingonashirt.org.
You won’t need a whole new wardrobe
It’s true that, when you don’t have breasts, there are a few styles that you will likely need to say ta-ta to. Anything with darts, or that is designed to reveal ample cleavage, like a plunging V-neck, is going to sit very differently on your post-explant body. That said, a surprising number of my pre-surgery clothes still work on my flat frame. And while I was sad to lose some tops that no longer flattered me, getting rid of them opened up space in my closet for new styles that I could never have worn back in the days when I needed a bra. I adore my skinny spaghetti straps, flirty little sundresses, and off-the-shoulder looks. And good golly, I love the way I look in a halter top now! For some next-level sexy, there’s even a line of lingerie made by flat women specifically for flat women! (More about The Skarlette).
You don’t have to wear prostheses
Not everybody wants to wear prostheses (in fact, for many patients, never having to wear a bra again is the silver lining of mastectomy surgery). If you choose not to wear “foobs,” and instead to present as flat, that doesn’t mean you have to “come out” about your breast cancer. Surprisingly, many flatties, including ones who had very large breasts before their surgery, find that no one notices their flatness. I was a C cup before surgery, and I have never worn prostheses; I waltz through my life flat as a board, and no one gives me a second look.
That said, there are flatties who straight-up love their foobs. Those who are unilaterally flat, in particular, may find that having a little weight and fullness on their flat side makes them feel more comfortable. Many prostheses are covered by insurance, and they come in a wide variety of materials, shapes and sizes. A good mastectomy bra and prosthesis can balance you out and camouflage your flatness, allowing you to wear pretty much anything from your pre-mastectomy wardrobe. If you are feeling playful, you can even treat foobs like an accessory, sizing up or down or going without, depending on your mood!
Your sex life isn’t over
Honestly, this topic is complex and sensitive enough to merit its own blog post. I can’t possibly do justice to the emotional journey that is sexuality after breast cancer in a paragraph or two. So I’ll just leave you with two things to chew on.
The first is the question of sensation. No matter how good your reconstructed breasts may look, chances are they’re mostly numb. So you’ve already had to adjust to that loss. On the bright side, many patients who explant to flat say they are less conscious of the numbness because there’s just less surface area that lacks sensation.
And for those who are convinced that their reconstructed breasts are the source of their sex appeal, I offer these words from Sexy M.F.: “No, not your body, your mind, you fool.” I rest my case. No one is going to tell me that Prince didn’t know from sexy!
All kidding aside, it may take some work for you to regain your sexual confidence after surgery. And the first step is to love yourself as fiercely as you wish to be loved by others. In “Flat and Happy,” I describe my decision to go flat as an act of radical self love. And I know so many flatties who feel more fully themselves now than they did before losing their breasts. I believe that’s because they’ve been tested, and have found themselves to be more independent-minded and stronger than they ever knew.
If you are “flat curious” but feeling stuck in your decision-making, you can learn more in Katrin van Dam’s book, Flat and Happy. It offers practical, straightforward guidance about aesthetic flat closure, as well as tools for assessing whether living flat is a good option for you. Read more at katrinvandam.com.