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Nina Katayama has had “something like a thousand appointments” since a 3-D mammogram revealed an aggressive form of breast cancer that had already spread to her lymph nodes.

The 51-year-old Minneapolis woman began her medical treatment with five months of chemotherapy, then underwent a double mastectomy in June of 2019. That was followed by eight weeks of radiation and additional rounds of chemotherapy.

One of the doctors she didn’t see was a plastic surgeon.

Almost from the moment of her diagnoses, Katayama knew she didn’t want an operation to rebuild her breasts.

“I have co-workers who wound up needing multiple surgeries, with stretching their skin and more trauma. So I said, ‘No, I’m not going to go through that’ and I’ve had no second thoughts,” she said. “My breasts aren’t small, they’re nonexistent. That’s just me now.”

Reconstruction surgery after a mastectomy or lumpectomy aims to restore the breast to its previous shape, size and symmetry by using implants or taking tissue from another part of the woman’s body. Numerous studies have concluded that reconstruction after surgery contributes to the psychological well-being of women recovering from breast cancer.

But a growing number of breast cancer survivors like Katayama are choosing to forgo such procedures. Many of the women who “go flat” also decline to use a bra with prostheses to create any sort of breast shape, preferring instead to live with a perfectly level chest.

Dr. Michaela Tsai understands why.

“Reconstruction is not a boob job,” said Tsai. “Mastectomies are big surgeries and while reconstruction techniques have vastly improved, reconstruction is the hardest part and most painful part. And it’s often not just one procedure, it requires two or three revisions.”

A Minneapolis oncologist who has worked primarily with breast cancer patients throughout her 20-year career, Tsai said she’s seen an uptick in women who are forgoing reconstruction in the past five years.

“Reconstruction is not everyone’s cup of tea,” said Tsai. “I remain neutral on whether they should do it. Flat is a fine option. My patients who go that way are pretty happy with the decision.”

‘I want to be visible’

Women who have had their breasts removed are becoming more vocal and visible, connecting through Facebook groups, online forums and Meetup gatherings. They show their style in flattering and cleavage-free YouTube videos, Instagram feeds, fashion blogs and Pinterest pages. There’s even a “Flat Is Where It’s At” podcast hosted by and featuring women who decided against reconstruction.

“We want to put flat on the menu,” said Sondra Price, president and one of the founders of the national nonprofit Flat Closure Now. “When I was diagnosed, implants were the only option presented to me. I had tons of complications with my implants for seven years and I wanted them out.”

The two-year-old advocacy group, which promotes “going flat is a valid, beautiful, healthy surgical option after mastectomy,” supports women who didn’t reconstruct or, like Price, went flat after explant surgery.

According to the American Society of Plastic Surgeons, some 19,000 breast cancer patients had their breast implants removed in 2017, a 19% increase since 2000. They chose to explant because of medical complications, discomfort, dissatisfaction with the implants’ appearance or worry about the impact on their health. A 2019 study found silicone implants to be associated with higher rates of autoimmune disorders.

“Before my reconstruction my doctors told me, ‘We will rebuild what you lost and it will make you happy.’ But I felt a disconnect from my body,” said Price. “When they unwrapped my chest the day after my explant and I had a flat chest I thought, ‘I’m myself again.’ ”

Melissa Jansen, who had one of her breasts removed after a cancer diagnosis and is flat on one side, curates The website illustrates fashion options for women who have had a unilateral mastectomy.

“This is a rising movement, another form of body positivity,” she said. “We don’t have to modify our bodies to be proud of them and be considered beautiful and sexy. I’m not ashamed that I had cancer. I didn’t want to put on a prosthetic and pretend it didn’t happen. I want to be visible.”

Considering the options

It’s not the cost of the reconstruction that prompts some women to choose to go flat.

In 1998, Congress passed the Women’s Health and Cancer Rights Act, which requires health insurance companies to cover the cost of breast reconstruction after a cancer-related mastectomy, including follow-up surgeries. The Breast Reconstruction Awareness Fund is available to cover costs for uninsured or underinsured women.

“Activists pushed for coverage and that’s a good thing, to have reconstruction paid for. But I keep hearing that many doctors still assume this is what all women want and should have,” said Barbra Wiener of Minneapolis.

Wiener was ahead of the curve, choosing a flat chest years before the current trend began. She had her breasts surgically removed in 1991, when she was 40 and has never once worn prosthetics to achieve a more traditional form.

“I don’t have to wear a bra. I have total freedom of movement,” she said.

Wiener opted for a preventive double mastectomy when such surgery was still quite rare, years before celebrities like Angelina Jolie and Christina Applegate chose that option based on their genetic histories.

Wiener’s mother died from breast cancer at age 56; three years later, her younger sister died from the same disease at age 29.

At the time, Wiener’s surgery seemed radical. “People told me I was out of my mind to cut off my breasts, but I wanted to eliminate my risk,” she said.

As for reconstruction? She never considered it. “It wasn’t important to me,” she said. “I am a whole person with or without breasts.”

A longtime women’s health advocate, Wiener isn’t shy about revealing her flat chest to women contemplating their options.

“When I meet with them, I say, ‘Would you like to see?’ and they always do. It’s my public service. Most women never get to see someone who hasn’t had breast reconstruction.”

That’s not to say that the loss of breasts isn’t wrenching.

“I did pretty good not missing my hair but it was hard to lose my breasts. I liked them,” admits Katayama. “At first I surprised myself when I looked in the mirror. Now I say, that’s how I look now. I’m learning to love myself. It’s a process.”

She credits her supportive husband with helping with her adjustment. She said she spends more of her energy coping with neuropathy and other persistent side effects of chemotherapy than she does thinking about her chest.

“Dealing with cancer is a full-time job; it takes so much energy. I’m strong but exhausted,” said Katayama. “It hasn’t been easy but not putting myself through the process of reconstruction means I have one less thing to worry about.”

Kevyn Burger is a Minneapolis-based freelance broadcaster and writer.