When Angelina Jolie had a double mastectomy in May 2013, many of us heard about it; she appeared on several talk shows and did a number of high-profile interviews. When we saw her just a few months later after the well-publicized surgery, she looked exactly the same — her well-known figure intact. That's because even though Jolie had her breast-tissue taken out, she opted to have reconstructive surgery, replacing both breasts with implants.

She wrote about the steps she took in a New York Times editorial, which detailed her first test and then the surgery for the breast tissue removal. Then, she wrote, "Nine weeks later, the final surgery is completed with the reconstruction of the breasts with an implant. There have been many advances in this procedure in the last few years, and the results can be beautiful."

Jolie should be commended for writing about her ordeal, which did a lot to raise awareness about breast cancer and women's health. But a growing number of women are questioning the assumption that breast implants are the logical final step of the mastectomy process.

'I just wanted to heal'


The women who eschew implants or any other type of reconstructive surgery call their choice "going flat." It's a straightforward descriptor of their post-mastectomy physical state. You can hear one woman's story in the video above.

Another woman, Debbie Bowers, told the New York Times that she declined the implants, even when her doctor told her were covered under her insurance plan: “Having something foreign in my body after a cancer diagnosis is the last thing I wanted,” said Bowers. “I just wanted to heal.”

While some women take issue with having artificial objects inside their body, other women cite the possible issues and trauma of an additional surgery when their body has already been through an ordeal. Up to one-third of women who go through reconstructive surgery experience complications.

“That’s the dirty little secret of breast reconstruction: The risk of a major complication is higher than for the average elective surgery,” Dr. Clara Lee, an associate professor of plastic surgery at Ohio State University who performs the procedure, told the Times.

This sounds like a personal choice, yet some women say they have been pressured to get implants, even if they don't think it's right for them. Doctors usually recommend the procedure as an important "quality of life" consideration post-mastectomy — even though a systematic review of women post-mastectomy found that those who went flat did just as well (and in some cases better) than those who chose implants.

Some doctors simply don't offer an option besides reconstruction, but other doctors have gone much further. One doctor in the Times' story left skin flaps for implants in case the patient changed her mind about going flat, and another told her she would look "deformed" without reconstructive surgery. Some going-flat advocates push that point much further, saying that many surgeons are men, which may lead them to recommend what they personally think looks good rather than asking their patients what they want.

These stories are disturbing, and while it seems obvious that a woman is still a woman even without her breasts, this point is a common refrain in the "going flat" social media community. The idea that there's something wrong with not wanting implants is one they are trying to make the medical community — and other women with breast cancer — aware of. Photo projects, short films and Facebook groups provide information and community around what's still seen by some doctors as an unusual choice. Breastfree is a whole website dedicated to going flat and celebrating the women who choose it.

It's a personal choice

Woman covering her breasts There's no right or wrong answer to the reconstruction question. (Photo: Fotos593/Shutterstock)

It's important to remember that all of these cultural expectations and judgments, decisions and choices are made by women during an incredibly vulnerable time, so the biases of doctors can play a heightened role in self-perception. "No matter the advice I received, the first, second or third-hand insights others shared with me or the research I did beforehand, the first time I stood in front of a mirror afterwards, naked and vulnerable, I broke down, the shock of my appearance nearly undoing my last shreds of strength,” Lisa told Today.com.

The Breastcancer.org site puts it well: "The decision to reconstruct or not is very personal. There is no 'right way' to approach mastectomy and reconstruction (or lack of it). There is only the way that is best for you, your preferences, and your healing." The site also includes useful information about going flat, questions to ask a doctor about the procedure, aesthetic considerations based on body type, and other information.

"I feel empowered that I made a strong choice that in no way diminishes my femininity," Jolie explained, of her decision to remove her breast tissue and replace it with implants. Women who have decided to go flat are challenging the idea that implants — or breasts at all — have anything to with femininity.

Starre Vartan ( @ecochickie ) covers conscious consumption, health and science as she travels the world exploring new cultures and ideas.